Job Description

Job Details: Level: Experienced,

Job Location: Milwaukee - Waukesha, WI 53186,

Position Type: Full Time, Education Level: High School Diploma or GED,

Salary Range: $95,000.00 - $105,000.00 Salary/year,

Travel Percentage: None,

Job Shift: Day,

Job Category: Admin - Clerical, POSITION SUMMARY: Under minimal supervision, oversees the daily operations of a workers’ compensation claims unit, ensuring timely, accurate, and high-quality claims handling in compliance with applicable state laws, client requirements, and company policies and procedures.

Provides technical guidance, training, and performance oversight to assigned staff and regularly interacts and collaborates with clients, management, Claims Examiners, and other TRISTAR personnel to resolve claims and service issues.

DUTIES AND RESPONSIBILITIES

• Directly supervises examiners and clerical staff, including, but not limited to, monitoring attendance, job performance, evaluations and disciplinary issues. *
• Participates in new hire processes as needed (interviewing, training, Personnel Action Formks (PAF)). *
• Monitors daily staffing needs, ensures daily caseload staffing requirements are met and distributes caseloads as equitably as practical amongst direct reports.
• Reviews and addresses scheduled claims issues, such as initial and periodic reviews, delays, denials, etc.*
• Performs file reviews to monitor accuracy and compliance with policies and laws. *
• Ensure consistent and accurate claim coding. *
• Prepares team meeting agenda and leads team meetings with direct reports. *
• Makes daily claims decisions as it pertains to claim strategies, action plans, handling of payments/recoveries, carrier/excess reporting and the like. *
• Runs supervisory reports as necessary to monitor performance and assist direct reports. *
• Reviews and approves reserve changes and payments within Company and Client guidelines. *
• Establishes appropriate supervisory diaries on claim files and completes pending diaries on or before scheduled due dates. *
• Prepares for claim audits, reviews audit results, and provides appropriate rebuttal feedback. *
• Coordinates, conducts and leads internal and external educational/training sessions for updated laws, policies, and procedures. *
• Responds to claimant and vendor concerns and facilitates timely resolution. *
• Evaluates vendor effectiveness and modifies vendor panels as needed within TRISTAR and account guidelines. *
• Ensure all staff adhere to client service instructions and applicable State reporting requirements. *
• Provides claims handling coverage during examiner absences and position vacancies. *
• Prepares, evaluates and analyzes monthly client reports. *
• Coordinates, facilitates and supports internal and external audits. *
• Participates in client file/claim reviews and addresses action items. *
• Partners with the corporate office and sales and service teams on requests for proposals (RFPs) and client service issues. *
• Adheres to TRISTAR’s Best Practices. *
• Performs 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.

Qualifications: QUALIFICATIONS REQUIRED:

Education/Experience: Bachelor’s degree in related field (preferred); five (5) plus years related experience; or equivalent combination of education and experience.

Knowledge, Skills and Abilities

• Strong technical knowledge of multi-state workers’ compensation laws, regulations, and medical terminology.
• Ability to maintain a claims diary system, prioritize work, and meet strict deadlines.
• Strong analytical and problem-solving skills.
• Proficiency in Microsoft Word and Excel.
• Excellent written and verbal communication skills, including the ability to explain technical claims information clearly to claimants, clients, and staff.
• Ability to supervise, coach, and develop employees with varying levels of experience and technical ability.
• Strong interpersonal skills and the ability to maintain effective working relationships.
• Ability to manage competing priorities and remain effective under pressure.
• Ability to model a positive, professional attitude to direct reports.
• Ability to respond promptly to client requests and service needs.

Other Qualifications

• Certifications and/or licenses 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):