About this role
POSITION SUMMARY: Under close to moderate supervision, manages workers compensation medical-only claims from inception through resolution, with total claim exposure not exceeding $10,000 and within assigned authority limits and established company and client guidelines.
Coordinates medical treatment, reviews medical billing, maintains accurate claim documentation, and communicates with clients, claimants, employers, medical providers, and TRISTAR staff. Identifies and promptly escalates claims involving potential indemnity benefits, increased exposure, disputed issues, or complexity beyond the medical-only scope.
DUTIES AND RESPONSIBILITIES:
- Manages medical-only workers compensation claims with total exposure up to $10,000, within assigned authority limits and under close to moderate supervision.*
- Initiates and conducts timely investigations to gather information needed to evaluate claims. *
- Determines compensability of medical-only claims in accordance with applicable state laws and company guidelines, seeking supervisory guidance on disputed or unusual matters. *
- Coordinates and monitors medical treatment and medical billing, providing authorization within assigned authority. *
- Communicates professionally with claimants, employers, medical providers, and vendors regarding claim status, treatment, billing, and other claims issues. *
- Calculates, establishes, and adjusts reserves within assigned authority and company guidelines.
- Monitors claims for lost time, potential indemnity benefits, increased medical exposure, litigation, or other developments requiring supervisory review or reassignment. *
- Promptly refers claims exceeding $10,000 in total exposure or the medical-only scope to the supervisor for review and appropriate reassignment. *
- Maintains a diary system for timely case review and documents claim files to accurately reflect claim status and handling activities. *
- Promptly communicates relevant information to clients, including injury trends and safety concerns. *
- Adheres to all company policies, procedures, and applicable client claims handling instructions. *
- Participate in file reviews as needed.
- Performs other duties as assigned.
*Essential job function.
EQUIPMENT OPERATED/USED: Computer, 10-key, fax machine, copier, printer and other office equipment.
SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire.
Qualifications
QUALIFICATIONS REQUIRED:
Education/Experience : Bachelors degree in related field (preferred); and one (1) to three (3) years related experience; or equivalent combination of education and experience.
Knowledge, Skills and Abilities :
- Working knowledge of applicable workers compensation laws, statutory requirements, and medical terminology relevant to medical-only claims.
- Ability to investigate and manage medical-only claims within assigned authority and established guidelines.
- Analytical skills to evaluate claim information, medical documentation, and billing.
- Ability to recognize changes in claim exposure or complexity and seek supervisory guidance promptly.
- Strong organizational skills and the ability to maintain a diary system, prioritize tasks, and meet deadlines.
- Effective written and verbal communication skills, including the ability to explain claims information clearly to claimants, clients, and staff.
- Ability to interact professionally with individuals at all levels of the business environment.
- Proficiency in Microsoft Word and Excel preferred.
Other Qualifications :
- Certification and/or or license as required by State regulation.
Mental and Physical Requirements : [see separate attachment for a copy of checklist of mental and physical requirements]
MENTAL AND PHYSICAL REQUIREMENTS
1. MENTAL EFFORT
a. Reasoning development:
Follow one- or two-step instructions; routine, repetitive task.
Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables.
Follow written, verbal, or diagrammatic instructions; several concrete variables.
Solve practical problems; variety of variables with limited standardization; interpret instructions.
X Logical or scientific thinking to solve problems; several abstract and concrete variables.
Wide range of intellectual and practical problems; comprehend most obscure concepts.
b. Mathematical development:
Simple additional and subtraction; copying figures, counting, and recording.
Add, subtract, multiply, and divide whole numbers.
X Arithmetic calculations involving fractions, decimals, and percentages.
Arithmetic, algebraic, and geometric calculations.
Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.
Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; require theoretical application.
c. Language development:
Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.
Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.
Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.
Ability to compose original correspondence, follow technical manuals, and have increased contact with people.
X Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.
2. PHYSICAL EFFORT
a. Physical activity required to perform the job:
X Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
Light work:
a. Exerting up to 20 pounds of force occasionally
b. Exerting up to 10 pounds frequently
c. Exerting a negligible amount of force constantly to move objects
(If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).
Medium work:
a. Exerting up to 50 pounds of force occasionally
b. Exerting up to 20 pounds of force frequently
c. Exerting up to 10 pounds of force constantly to move objects
Heavy work:
a. Exerting up to 100 pounds of force occasionally
b. Exerting up to 50 pounds of force frequently
c. Exerting up to 20 pounds of force constantly to move objects
Very heavy work:
a. Exerting in excess of 100 pounds of force occasionally
b. Exerting in excess of 50 pounds of force constantly to move objects
c. Exerting in excess of 20 pounds of force constantly to move objects
- Visual requirements necessary to perform the job:
Far vision: clarity of vision at 20 feet or more
X Near vision: clarity of vision at 20 inches or less
X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet
Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are
Color vision: ability to identify and distinguish colors
Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point
2. PHYSICAL EFFORT (cont.)
FREQUENCY
c. Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):
Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.
Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.
Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.
Kneeling: Bending legs at knee to come to a rest on knee or knees.
Crouching: Bending the body downward and forward by bending legs and spine.
Crawling: Moving about on hands and knees or hands and feet.
Reaching: Extending hand(s) and arm(s) in any direction.
Standing: Particularly for sustained periods of time.
Walking: Moving about on foot to accomplish tasks, particularly for long distances.
Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.
Pulling: Using the upper extremities to extend force in order to drag, haul, or tug objects in a sustained motion.
Foot
Motion: Using feet to push pedals.
Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.
X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.
X Grasping: Applying pressure to an object with the fingers and palm.
Frequently
Occasionally
2. PHYSICAL EFFORT (cont.)
FREQUENCY
X Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.
X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication and to make fine discriminations in sound, such as when making find adjustments on machined parts.
Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.
X Repetitive Substantial movements (motions) of the wrists, hands,
Motion: and/or fingers.
Frequently
Frequently
Frequently
3. WORKING CONDITIONS
Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure.
WORKING CONDITION
ENVIRONMENTAL
FACTOR
NATURE/REASON
OF EXPOSURE
FREQUENCY
Dirt/Dust
Noise
Temperature extremes
Dampness
Vibrations
Equipment movement hazard
Chemicals/solvents
Electrical shock
Significant work pace/pressure
Odors/Fumes
Other (specify):