• Utilization Review Claims Examiner

    Job Location(s) US-CA-Santa Ana
    Job ID
    # of Openings
    Utilization Review
    Job Type
    Regular Full-Time
  • Overview


    POSITION SUMMARY: Under close supervision performs clerical and data entry tasks that assist in the performance of Utilization Review.


    This position requires considerable interaction with management, other Claims Examiners, and other TRISTAR staff in the office; therefore consistently being at work in the office, in a timely manner, is inherently required of this position. This position also requires the review of sensitive medical reporting.




    • Prints and collates medical requests for authorization from a dedicated Utilization Review email/fax line.*
    • Reviews and triages medical treatment requests
    • Documents all work product and claim activity in the electronic claim file.*
    • Performs data entry for the completion of Utilization Review either through internal processes or via a third party vendor.*
    • May prepare and send communications via fax or U.S. mail to appropriate parties including the client, injured worker, medical provider, non-medical provider, and applicant legal counsel.*
    • May prepare and send medical records to Independent Medical Review contractor, MAXIMUS Federal Services, Inc. via electronic submission.*
    • Answers phone calls, take messages and responds appropriately.*
    • Provides clerical support, including filing, faxing, sorting, and alphabetizing.*
    • Other duties as assigned.


    *Essential job function.


    EQUIPMENT OPERATED/USED: Computer, telephone, 10-key, fax machine, printers and other basic office equipment.



    SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire.





    Education/Experience: High school diploma or GED required, College degree (preferred) and six (6) months experience in the Workers’ Compensation claims industry (preferred) and passing the Self Insurance Administrator Competency (SIP) within six months of starting the position. (required)


    Knowledge, Skills and Abilities:

    • Proficient keyboarding skills (type 45 wpm).
    • Working knowledge of medical/legal terminology.
    • Ability to alphabetize and collate.
    • Proficient in Word.
    • Ability to follow written and spoken instructions from several individuals.
    • Ability to produce accurate and detailed work.
    • Excellent verbal and written communication skills.
    • Courteous telephone skills.
    • Ability to effectively prioritize multiple projects and due dates.
    • Ability to work independently, as well as in cooperation with workgroup.


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