POSITION SUMMARY: Under minimal supervision manages and directs activity of claims unit ensuring high-quality results and management of claims in compliance with state laws and company procedures.
This position requires considerable interaction with clients, 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.
DUTIES AND RESPONSIBILITIES:
Directly supervises examiners and clerical staff. Includes monitoring attendance, job performance, evaluations and disciplinary issues.
Reviews and addresses scheduled claims issues, such as initial and periodic reviews, delays, denials, etc.
Reviews and approves reserve changes, awards and payments within Company guidelines
Performs file reviews to monitor compliance with policies and laws.* This is completed file by file, monthly reviews as required by client and agency file reviews.
Coordinates and leads training sessions for staff on updated laws, policies and procedures.*
Ensures daily caseload staffing requirements are met.*
Supervises and approves priority payments; sign checks
Responds to claimant and vendor concerns and issues as needed.*
DUTIES AND RESPONSIBILITIES, continued
Monitors effectiveness of vendors and modifies panels as needed.*
Ensures client servicing instructions are being adhered to.*
Provides coverage for examiner vacancies due to vacation or vacancies.*
Prepares and evaluates monthly client reports.*
Facilitates internal and external audits.*
Conducts and documents in-house and outside educational sessions.
Attends client file reviews.
Partners with corporate office and sales/service team for RFP’s and client service issues.
Other duties as assigned.
*Essential job function.
EQUIPMENT OPERATED/USED: Computer, 10-key, printer, copier, fax machine and other office equipment.
SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire.
Education/Experience: Bachelor’s degree in related field (preferred); three (3) to five (5) years related experience; or equivalent combination of education and experience.
Knowledge, Skills and Abilities:
Technical knowledge of statutory regulations and medical terminology.
Ability to work on a diary system, prioritize tasks and meet strict deadlines.
Strong analytical skills.
Proficient in Word and Excel.
Excellent written and verbal communication skills, including ability to convey technical details to claimants, clients and staff.
Ability to manage employees of various skill levels.
Excellent interpersonal skills.
Texas Workers’ Compensation License
MENTAL AND PHYSICAL REQUIREMENTS
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.
X Solve practical problems; variety of variables with limited standardization; interpret instructions.
Logical or scientific thinking to solve problems; several abstract and concrete variables.
Wide range of intellectual and practical problems; comprehend most obscure concepts.
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; requires theoretical application.
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.
Physical activity required to perform the job:
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.
X Light work:
Exerting up to 20 pounds of force occasionally
Exerting up to 10 pounds frequently
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).
Exerting up to 50 pounds of force occasionally
Exerting up to 20 pounds of force frequently
Exerting up to 10 pounds of force constantly to move objects
Exerting up to 100 pounds of force occasionally
Exerting up to 50 pounds of force frequently
Exerting up to 20 pounds of force constantly to move objects
Very heavy work:
Exerting in excess of 100 pounds of force occasionally
Exerting in excess of 50 pounds of force constantly to move objects
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
PHYSICAL EFFORT (cont.)
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.
X 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.
X Kneeling: Bending legs at knee to come to a rest on knee or knees.
X Crouching: Bending the body downward and forward by bending legs and spine.
Crawling: Moving about on hands and knees or hands and feet.
X Reaching: Extending hand(s) and arm(s) in any direction.
X Standing: Particularly for sustained periods of time.
X Walking: Moving about on foot to accomplish tasks, particularly for long distances.
X Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.
X Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion.
Motion: Using feet to push pedals.
X 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.
PHYSICAL EFFORT (cont.)
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.
Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure.