TRISTAR Insurance Group

Claims Specialist

• Manage approximately 150–180 workers’ compensation claims of moderate to complex difficulty
• Manage indemnity claims from inception through resolution within assigned authority limits and company/client guidelines
• Calculate and establish reserves
• Authorize payments and settlements within assigned authority limits
• Identify and escalate claims involving significant exposure, unusual compensability issues, sensitive client concerns, or decisions exceeding authority
• Refer claims to defense counsel as appropriate
• Monitor litigation activities
• Consult with the supervisor on significant legal developments and settlement strategy
• Exercise independent judgment in routine and complex claims handling
• Seek supervisory guidance on unusual, high-exposure, or sensitive matters

Workers Compensation Claims Examiner II

Claims Assistant

• Provide clerical, administrative, and data-entry support for workers’ compensation claims administration
• Support Claims Examiners with claim setup, payment processing, correspondence, regulatory filings, and records maintenance
• Communicate with claimants, medical providers, employers, investigators, attorneys, management, and TRISTAR staff
• Enter new claim information and establish claim files in the claims management system
• Assist with telephone communications concerning light-duty claims as directed
• Support scheduled payment processing under Claims Examiner direction
• Process special mailing requests according to instructions and deadlines
• Prepare PLN notices and other state filings using information provided or approved by Claims Examiners
• Assist with mail processing and check printing
• Enter payments as directed by authorized claims staff
• Receive, organize, and distribute incoming mail; prepare outgoing correspondence and claim-related documents
• Copy, scan, and organize documents
• Answer and route telephone calls, record messages, and direct inquiries
• Prepare, generate, and run claims management system reports
• Maintain accurate records and report missing information or processing discrepancies
• Perform other duties as assigned

Claims Assistant – Workers' Compensation

Supervisor

• Oversee the daily operations of a workers’ compensation claims unit
• Ensure timely, accurate, and high-quality claims handling in compliance with applicable state laws, client requirements, and company policies and procedures
• Provide technical guidance, training, and performance oversight to assigned staff
• Supervise Claims Examiners, Claims Assistants, and potentially Administrative Support
• Monitor daily staffing needs and distribute caseloads among direct reports
• Review and approve priority payments and sign checks as authorized
• Respond to claimant and vendor concerns and facilitate timely resolution
• Evaluate vendor effectiveness and modify vendor panels as needed
• Ensure staff follows client service instructions
• Provide claims handling coverage during examiner absences and position vacancies
• Prepare and evaluate monthly client reports
• Coordinate and support internal and external audits
• Conduct and document internal and external educational sessions
• Participate in client file reviews and address resulting action items
• Partner with the corporate office and sales and service teams on RFPs and client service issues
• Adhere to TRISTAR’s Supervisor Best Practice Guidelines
• Perform other duties as assigned

Workers Compensation Claims Supervisor

• Manage workers’ compensation medical-only claims from inception through resolution, with total exposure not exceeding $10,000 and within assigned authority limits
• Initiate and conduct timely claim investigations
• Determine compensability in accordance with applicable state laws and company guidelines
• Coordinate and monitor medical treatment and medical billing
• Communicate with claimants, employers, medical providers, vendors, clients, and TRISTAR staff
• Calculate, establish, and adjust reserves within assigned authority and company guidelines
• Monitor claims for lost time, potential indemnity benefits, increased medical exposure, litigation, or other developments
• Refer claims exceeding $10,000 or the medical-only scope to a supervisor
• Maintain a diary system and accurate claim documentation
• Communicate injury trends and safety concerns to clients
• Participate in file reviews and perform other assigned duties

Workers' Compensation Claims Examiner I - Medical Only

• Manage all aspects of Professional Liability claims from inception through resolution within established authority and company guidelines
• Review policy information, endorsements, and vehicle schedules to determine coverage for loss, damage, or injury
• Examine and investigate claims, including matters in litigation, through final resolution
• Interact frequently with claimants and their legal representatives
• Communicate loss exposure, reserves, and settlement strategy recommendations to clients
• Review, process, and conclude assigned claims
• Interpret policies and make coverage determinations
• Oversee and direct outside investigative service providers
• Work with clients, client counsel, and investigative services to advance claims
• Maintain an ongoing claim diary
• Assess exposure and evaluate reserves and settlement recommendations
• Prepare detailed Loss Reports analyzing liability and damages
• Determine and initiate subrogation or risk-transfer recovery efforts when applicable
• Document correspondence, reports, discussions, and decisions in claim files
• Provide outstanding client service
• Assist supervisors and the Claims Department with requested tasks and special projects
• Perform other duties as assigned
• Work remotely from home under the oversight of the Area Manager and reporting to the Claim Supervisor and/or Area Manager

Professional Liability Claims Examiner III

• Independently manage approximately 125–150 highly complex workers’ compensation indemnity claims in the Texas jurisdiction from inception through resolution
• Evaluate difficult compensability, medical, disability, and litigation issues
• Develop claims resolution strategies
• Establish and adjust reserves and authorize payments and settlements within assigned authority limits
• Direct defense counsel and evaluate litigation strategy, significant legal developments, and settlement recommendations
• Prepare detailed captioned reports covering claim status, exposure, reserves, litigation strategy, and recommended resolution
• Escalate matters exceeding assigned authority or requiring management involvement
• Provide technical guidance to less experienced Claims Examiners without formal supervisory responsibility

Workers Compensation Claims Examiner III

• Manage all aspects of Professional Liability claims from inception through resolution within established authority and company guidelines
• Review policy information, endorsements, and vehicle schedules to determine coverage for loss, damage, or injury
• Examine and investigate claims, including matters in litigation, through final resolution
• Interact frequently with claimants and their legal representatives
• Communicate recommendations regarding loss exposure, reserves, and settlement strategy to clients
• Review, process, and conclude assigned professional liability claims
• Interpret policies and make coverage determinations
• Oversee and direct outside investigative service providers
• Work with clients, client counsel, and investigative services to advance claims to conclusion
• Maintain an ongoing claim diary
• Assess exposure and evaluate reserves and settlement recommendations
• Prepare detailed Loss Reports analyzing liability and damages
• Determine and initiate subrogation or risk-transfer recovery efforts when applicable
• Document correspondence, reports, discussions, and decisions in claim files
• Provide outstanding client service
• Assist supervisors and the Claim Department with requested tasks or special projects
• Work remotely from home under the oversight of the Area Manager and reporting to the Claim Supervisor and/or Area Manager

Professional Liability Claims Examiner, III

• Manage workers’ compensation medical-only claims from inception through resolution, with total claim exposure not exceeding $10,000 and within assigned authority limits
• Initiate and conduct timely investigations to gather information needed to evaluate claims
• Determine compensability of medical-only claims in accordance with applicable state laws and company guidelines
• Coordinate and monitor medical treatment and medical billing, providing authorization within assigned authority
• Communicate with claimants, employers, medical providers, vendors, clients, and TRISTAR staff regarding claim status, treatment, billing, and other claims issues
• Calculate, establish, and adjust reserves within assigned authority and company guidelines
• Monitor claims for lost time, potential indemnity benefits, increased medical exposure, litigation, or other developments requiring supervisory review
• Refer claims exceeding $10,000 in total exposure or the medical-only scope to a supervisor
• Maintain a diary system for timely case review and document claim files accurately
• Communicate relevant information to clients, including injury trends and safety concerns
• Adhere to company policies, procedures, and client claims-handling instructions
• Participate in file reviews and perform other duties as assigned

Workers' Compensation Claims Examiner I – Medical Only

• Manage workers’ compensation indemnity claims of moderate to complex difficulty from inception through resolution
• Exercise independent judgment in routine and complex claims handling
• Seek supervisory guidance on unusual, high-exposure, or sensitive matters
• Manage a caseload of approximately 150–180 workers’ compensation claims
• Calculate and establish reserves
• Authorize payments and settlements within assigned authority limits
• Identify and escalate claims involving significant exposure, unusual compensability issues, sensitive client concerns, or decisions exceeding assigned authority
• Refer claims to defense counsel as appropriate
• Monitor litigation activities
• Consult with the supervisor on significant legal developments and settlement strategy

• Manage all aspects of complex and litigated indemnity claims from inception to conclusion within established authority and guidelines
• Manage a caseload of indemnity claim files, including very complex and litigated claims
• Initiate and conduct timely investigations
• Determine compensability of claims and administer benefits based upon state law and TRISTAR Best Practices
• Manage medical treatment and medical billing, authorizing as appropriate
• Refer cases to outside defense counsel and participate in litigated matters
• Communicate with claimants, attorneys, providers, and vendors regarding claims issues
• Compute and set reserves within Company guidelines
• Settle and/or finalize claims and obtain authority as designated
• Maintain diary system and document files, including plans of action
• Communicate information to clients to resolve claims efficiently, including injury trends and safety-related concerns
• Conduct file reviews
• Identify and review claims for Apportionment assignment
• Identify and investigate subrogation potential and pursue recovery
• Identify claim standard criteria for excess reporting and reimbursement
• Assist with State Audit and reporting responses
• Mentor less experienced Examiners
• Perform other assigned duties, including claims management of other jurisdictional workers’ compensation claims
• Adhere to TRISTAR company policies and procedures

Claims Examiner III

• Manage all aspects of complex and litigated indemnity claims from inception to conclusion within established authority and guidelines
• Manage a caseload of indemnity claim files, including very complex and litigated claims
• Initiate and conduct timely investigations
• Determine claim compensability and administer benefits based on state law and TRISTAR Best Practices
• Manage medical treatment and medical billing, authorizing as appropriate
• Refer cases to outside defense counsel and participate in litigated matters
• Communicate with claimants, attorneys, providers, vendors, clients, and staff regarding claims issues
• Compute and set reserves within Company guidelines
• Settle and/or finalize claims and obtain designated authority
• Maintain diary systems, document files, and create plans of action
• Conduct client and management file reviews
• Identify and review claims for apportionment assignment
• Investigate subrogation potential and pursue recovery
• Identify claim standards for excess reporting and reimbursement
• Assist with state audit and reporting responses
• Mentor less experienced Examiners
• Perform other assigned duties, including claims management for other jurisdictional workers’ compensation claims
• Adhere to TRISTAR company policies and procedures

Operator

• Answer and assist with incoming calls, including first notice, and route them appropriately
• Manage a high-volume, multi-line telephone system
• Set up and enter liability, subrogation, and first notice of loss reports in claims/notice reporting systems or portals
• Accurately document each call and its outcome
• Monitor dedicated client email inboxes for new first notice loss reports
• Monitor phone lines and hold times and report excessive hold times to the supervisor
• Perform clerical duties and meet administrative, productivity, time-management, and quality-assurance standards
• Maintain confidentiality and comply with HIPAA and PHI regulations
• Use instant messaging, email, and Zoom to communicate with team members and supervisors
• Report phone-system issues, customer concerns, escalations, system or equipment issues, downtimes, and loss of access to remote resources
• Establish rapport with callers, guide them through the reporting process, and provide exceptional customer service
• Perform other duties as assigned

Telephonic Intake Operator

• Manage all aspects of indemnity workers’ compensation claims from inception to conclusion within established authority and guidelines
• Manage a caseload of 150 or fewer workers’ compensation files, including complex claims
• Initiate and investigate claims promptly
• Determine claim compensability and administer benefits based on state law and company guidelines
• Manage medical treatment and medical billing, authorizing as appropriate
• Refer cases to outside defense counsel and direct/manage them as appropriate
• Communicate with claimants, providers, and vendors regarding claims issues
• Compute and set reserves within company guidelines
• Settle and finalize claims and obtain designated authority
• Maintain diary systems and document claim files
• Communicate information to clients to resolve claims efficiently, including injury trends and safety concerns
• Involve loss control staff when appropriate
• Conduct file reviews independently
• Adhere to company policies and procedures
• Perform other duties as assigned