Claims Specialist

• 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 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 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

• 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

• 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 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 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

• Investigate and confirm facts of loss for basic to advanced automobile accidents
• Determine coverage, liability, and damages
• Adjust and negotiate claims within limits of authority
• Determine subrogation or fraud potential and handling for complex cases
• Apply advanced understanding of company insurance policies, the industry, and organizational relationships
• Investigate complex auto claims involving coverage, liability, and damages
• Review, evaluate, and negotiate moderate to complex injury claims when handled
• Recognize vehicle body parts and assess other potential property damage
• Identify customer needs and address them using appropriate customer service skills
• Work collaboratively across teams
• No supervisory duties

MD Claims Adjuster, Experienced

• Analyze and process complex or technically difficult general liability claims
• Investigate and gather information to determine claim exposure
• Manage claims through action plans to timely and appropriate resolution
• Manage the litigation process and ensure cost-effective claims resolution
• Coordinate vendor referrals for additional investigation or litigation management
• Lead team meetings and assign accountability for follow-up items
• Gather compliance and claims processing information for team meetings
• Assist in interviewing adjusters and clerical staff and provide feedback to the hiring manager
• Support the team lead with monthly reviews of adjuster workloads, identify trends, and suggest adjustments
• May supervise up to three direct reports
• Administer company personnel policies and follow staffing and training standards
• Interview, hire, establish performance development plans, and conduct performance discussions
• Provide support, guidance, leadership, and motivation to promote maximum performance

Claims Examiner - Liability

• Investigate complex, catastrophic, and high-exposure workers’ compensation claims
• Perform three-point contact on all new losses and maintain detailed action plans with strategic resolution planning
• Identify fraud indicators and refer cases to SIU
• Gather and document facts on claims involving multi-party liability, catastrophic injury, significant subrogation potential, or novel legal issues
• Lead medical management, direct specialists, coordinate life care planners, direct UR and IMEs, and manage PTD cases
• Partner with case managers to maximize early return to work and review high-cost or unusual medical treatment
• Lead permanent disability ratings on complex cases
• Establish and adjust reserves on high-exposure files with documented justification
• Ensure status reports comply with client reporting timelines and formats
• Direct litigation, including selecting defense counsel, setting strategy, retaining experts, managing legal spend, and preparing for trial
• Lead mediations, settlement conferences, and arbitrations
• Make or recommend high-value settlement authority decisions with the Claims Supervisor and client
• Negotiate and finalize high-value settlements, including C&R and Stipulated Awards
• Manage multi-lien resolution and coordinate with lien counsel and CMS
• Pursue subrogation, multi-defendant contribution, and apportionment recovery
• Coordinate with recovery vendors and outside subrogation counsel
• Provide technical backup for the Claims Supervisor and guidance on complex decisions, reserve adequacy, and escalated client issues
• Mentor Adjuster I and II colleagues and support unit-wide quality review
• Serve as a senior contact for key client accounts and maintain client and carrier relationships
• Maintain proactive, transparent communication and respond within required timeframes

Claims Specialist jobs in Texas

Workers Compensation Claims Examiner III

Workers' Compensation Claims Examiner I - Medical Only

Workers Compensation Claims Examiner II

Professional Liability Claims Examiner III

Workers' Compensation Claims Examiner I – Medical Only

Professional Liability Claims Examiner, III

Workers Compensation Claims Examiner II

MD Claims Adjuster, Experienced

Claims Examiner - Liability

Worker's Compensation Claims Adjuster III