Claims Examiner III

Claims Examiner III This position is a hybrid in Sacramento - Rancho Cordova, CA 95670. Position Summary This will be a permanent floating examiner position to cover open desks due to vacations, leaves of absence, new business onboarding, increased pending inventories, auditing, etc. At the direction of the claims supervisor and/or manager, under minimal supervision, manages all aspects of workers' compensation claims (complex, litigated, non-disabling) claims from inception to conclusion within established authority and guidelines. Duties and Responsibilities Effectively manages a temporary caseload of workers' compensation claim files, including very complex and litigated claims. Initiates and conducts investigations in a timely manner. Determines compensability of claims and administers benefits based upon state law and TRISTAR best practices for claim handling. Manages medical treatment and medical billing, authorizing as appropriate. Refers cases to outside defense counsel and participates in litigated matters. Communicates with claimants, attorneys, providers and vendors regarding claims issues. Works in an organized and proactive manner. Computes and sets reserves within company guidelines. Settles and/or finalizes all claims and obtains authority as designated. Maintains a diary system for case review and documents file to reflect the status and work being performed on the file, including a plan of action. Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety related concerns. Conducts file reviews as scheduled by the client and management. Identifies and reviews claims for apportionment assignment. Identifies and investigates subrogation potential and pursues recovery. Identifies claim standard criteria for excess reporting and reimbursement. Assists with state audit and reporting responses. Mentors less experienced examiners. Adheres to all TRISTAR company policies and procedures. 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: Minimum five (5) or more years related experience; or equivalent combination of education and experience. Technical knowledge of statutory regulations and medical terminology. Analytical skills. Excellent written and verbal communication skills, including the ability to convey technical details to claimants, clients, and staff. Ability to interact with people at all levels in the business environment. Ability to independently and effectively manage very complex claims. Proficient in Word and Excel (preferred). Other qualifications: California self-insurance certificate. Here are some of the benefits you can enjoy in this role: Medical, dental, vision insurance. Life and disability insurance. 401(k) plan. Paid holidays. Paid time off. Referral bonus.

Created: 2026-03-04