Tristar Insurance

Role Description Provides oversight and leadership to a team of claims adjusters responsible for managing property, automobile, and liability claims from initial review through final resolution, including matters in litigation. Oversee policy interpretation and coverage determinations related to loss, damage, or injury, ensuring claims are investigated, evaluated, and resolved in an efficient, compliant, and cost-effective manner. Responsible for supervising adjusters handling large Self-Insured Retention (SIR) accounts and ensuring timely and accurate assessment of loss exposure, reserving practices, and settlement strategies. Ensures that claim developments, exposure evaluations, and strategic recommendations are effectively documented and clearly communicated to clients to support informed decision-making. Duties and Responsibilities - Oversee team that will review and interpret coverage, process, and conclude assigned claims including investigation and evaluation of Property, Auto and/or General Liability Casualty Claims. - Oversee teams’ direction of outside investigative service providers and work closely with the client and client counsel and investigative services to advance the claim to conclusion. - Maintain an ongoing diary. - Continually assess adjusting oversight of exposure and evaluate for accurate reserves and settlement recommendation. - Approve Loss Reports providing thorough analysis of coverage, liability, and damages. - Ensure team Subrogation and/or risk transfer exists and initiate recovery efforts. - Ensure team achieves success when tracked against specific KPI measurements. - Provide outstanding service to the client. Special Requirements - At least three years of Automobile Supervision experience required. - Knowledge of claims handling concepts, practices, and techniques, including but not limited to coverage issues, litigation management and product line knowledge. - Demonstrated verbal and written communications skills. - Demonstrated advanced analytical, decision-making and negotiation skills. - Computer proficiency. Preferred Skills - Ability to communicate effectively and clearly, both orally and in writing. - Ability to manage relationships in a fast-paced environment, while demonstrating problem solving and decision-making skills to collaborate with customers. - Good analytical abilities to review, exercise judgment and evaluate claims to make sound decisions with a minimal amount of supervision. - Excellent customer service skills. - An understanding of the litigation process and case valuation in multiple jurisdictions. - Ability to carry out detailed written or verbal instructions, ability to respond to requests effectively and efficiently and exhibit good common sense. - An ability to handle assigned claims following company guidelines and industry best practices with a minimal amount of supervision. - Time management skills, organizational skills, and ability to prioritize issues and tasks. - Ability to effectively operate computer equipment and applications. - Independence, flexibility, and creativity. Qualifications - Bachelor’s degree in a related field (preferred); seven (7) years related auto and general liability experience; or equivalent combination of advanced education and experience. - A minimum of three years’ supervisory experience is also required. Knowledge, Skills, and Abilities - Technical knowledge of statutory regulations. - 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 conveying technical details to claimants, clients, Supervisor reports and staff. - Ability to manage employees of various skill levels. - Excellent interpersonal skills. Other Qualifications - Certifications and/or licenses as required by State regulation. - Candidate must have a NY adjuster license. Equipment Operated/Used - Computer - 10-key - Printer - Copier - Fax machine - Other office equipment Special Equipment or Clothing - Appropriate office attire.

Role Description This is a remote position. Preference is remote in Texas. Work directly with the Supervisor and Manager to provide additional resources to the case management staff. This position does not provide any clinical review or decisions. This individual is responsible for ensuring the referrals are set up in the Utilization Review/Case Management system and promptly assigned to the case manager. The Case Management Assistant will: - Answer incoming calls, screen, respond, and route the calls. - Work independently to meet deadlines. - Exhibit an excellent phone demeanor and a desire to provide exceptional customer service. - Possess knowledge of medical terminology and understanding of referral criteria by client and/or jurisdictions. Qualifications - Education: High school diploma required. Medical or Managed Care background preferred and/or Certified Medical Assistant. - Experience: Minimum of one year of working in a medical or managed care environment preferred. Medical Terminology preferred. - Knowledge, Skills and Abilities: - Experience in healthcare related fields. - Strong communication skills; customer service mindset; team player. - Adheres to professional standards, codes of ethics, system and department policies and procedures. - Incorporates the philosophies of continuous quality improvement, customer service, and teamwork into daily routine. - Excellent typing and keyboard skills (35-40wpm). - Ability to work in a variety of computer systems proficiently. - Ability to navigate a Windows environment, utilize Outlook, and create, edit, save, and send documents utilizing Microsoft Word and Microsoft Excel. - Ability to work within a paperless environment. Requirements - Respond to phone inquiries from providers, patients, case managers, peer reviewers, and direct to the appropriate handling party. - Make initial contact for case management staff and providers to obtain clinical information. - Assist with case management workflow and documentation; prepare routine correspondence for Case Managers, physicians, and patients. - Identify each caller/patient’s needs and determine the next appropriate action, which may include clinic referral or identifying the necessity for the escalation process to be activated. - Communicate effectively with all parties, such as case managers, physicians, claims team, and ancillary providers and/or vendors/agencies to ensure that patient information is current, accurate, and complete. - Print and mail correspondence to all necessary parties in accordance with state rules and regulations. - Other duties as necessary assigned by supervisor. - Assist incoming calls to the case management department. - Monitor dedicated queues/emails. - Process all determinations and correspondence within 24 hours of receipt. - Actively participate as a member of the team, working collaboratively with and supporting other staff. - Complete the assigned deliverable/billable hours per week, as assigned by your Supervisor. - Identify trends and/or issues in referral patterns and communicate them with management. - Demonstrate ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards. - Maintain documentation standards adhering to URAC standards and company policy and procedures. - Maintain confidentiality - Knowledge of laws and regulations pertaining to HIPAA and PHI. Benefits - Professional attire adhering to the Company Dress Code.

Role Description Under minimal supervision, manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines. This position requires considerable interaction with clients, claimants on the phone, and with management, other Claims Examiners, and other TRISTAR staff in the office; therefore, consistently being at work on time is inherently required of this position. Duties and Responsibilities - Effectively manages a caseload of 150 or fewer workers’ compensation files, including complex claims. - Initiates and investigates promptly. - Determines compensability of claims and administers benefits based upon state law and following established Company guidelines. - Manages medical treatment and medical billing, authorizing as appropriate. - Refers cases to outside defense counsel. Directs and manages as appropriate. - Communicates with claimants, providers, and vendors regarding claims issues. - Computes and sets reserves within Company guidelines. Limits are more significant than those allowed for Claims Examiner I and Claims Examiner II. - Settles and finalizes all claims and obtains authority as designated. - Maintains diary system for case review and documents file to reflect the status and work performed on the file. - Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety-related concerns. - Involves TRISTAR loss control staff when appropriate. - Adheres to all Company policies and procedures. - Conducts file reviews independently. - Other duties as assigned. Qualifications - Bachelor’s degree in a related field (preferred); three (3) or more years of related experience; or equivalent combination of education and experience. - Must have an adjuster's license in Minnesota, Michigan & Indiana. - Technical knowledge of statutory regulations and medical terminology. - Analytical skills. - Excellent written and verbal communication skills, including conveying technical details to claimants, clients, and staff. - Ability to interact with persons at all levels in the business environment. - Ability to independently and effectively manage very complex claims. - Proficient in Word and Excel (preferred). Requirements - Must have an adjuster's license for Michigan, Minnesota & Indiana. Benefits - Medical, Dental & Vision Insurance - Life & disability Insurance - 401(k) plan - Paid holiday - Paid time off - Referral bonus

Role Description The Credentialing and Contracting Specialist is responsible for preparing and maintaining contracts and the contracts database system. Maintain active status for all providers by successfully completing initial and subsequent credentialing packages as required by state regulations, guidelines and policies. Essential Duties and Responsibilities - Reviews and screens initial and reappointment credentialing applications for completeness, accuracy, and compliance with regulations, guidelines, policies, and standards. Monitors Applications and follows-up as needed. - Conducts primary source verification, collects and validates documents (state license, DEA Certificates, malpractice coverage, etc.) to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards to ensure timely renewal. Maintains provider contract files. - Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners; discovers and conveys problems to Director for sound decision making in accordance with credentialing policies and procedures, state regulations. - Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies; prepares and provides information to internal and external customers as appropriate. - Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures. - Prepares, issues, electronically tracks and follows-up on appropriate verifications for efficient, high-volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines. - Participates in the development and implementation of process improvements for the credentialing process. - Communicates clearly with providers, their liaisons, and staff as needed to provide timely responses upon request on day-to-day credentialing, provider, staff and client issues as they arise. - Assists in helping find available physician(s) when unavailable within the Network. - Maintains professional growth and development through professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry. - Performs miscellaneous job-related duties as assigned. Qualifications - Ability to communicate effectively both orally and in writing. - Customer service skills. - Ability to respond to emails timely and effectively. - Information research skills. - Knowledge of medical provider credentialing and accreditation principles, policies, processes, procedures, and documentation. - Ability to use independent judgment and to manage and impart confidential information. - Ability to maintain confidentiality and discretion in all communications on behalf of credentialing applicants and/or applications. - Ability to make administrative/procedural decisions and judgments. - Demonstrated advanced working knowledge of Microsoft Word and Excel. - Ability to learn new applications to function effectively in a remote work environment. - Skill in establishing priorities with independent coordination of day-to-day aspects. - Skills in computerized spreadsheeting and database management. - Ability to organize and prioritize work and manage multiple priorities. Requirements - High school diploma or equivalent required. - Computer skills required with knowledge in utilizing Outlook, Microsoft Word, Excel and other databases. Benefits - Medical, Dental, Vision Insurance - Life & Disability Insurance - Paid time off - Paid holidays - 401(k) plan - Referral bonus

Role Description This is a remote position. This examiner will handle either FL, NY, GA, or TX claims and must have the appropriate adjuster's license. Responsible for the prompt review of policy information including all relevant endorsements and vehicle schedules to determine coverage for loss/damage/injury. Conduct an efficient claim examination and investigation leading to the final resolution of liability claims, including matters in litigation. Frequent contact and interaction with involved parties including claimants and their legal representatives will be required. Recommendations regarding loss exposure and associated reserve and settlement strategy will be effectively communicated to the client. Duties and Responsibilities - Review, process and conclude assigned claims including investigation and evaluation of complex Commercial Auto and General Liability Casualty Claims. - Review and interpret policies, coverage determination. - Oversee and direct outside investigative service providers and work closely with the client and client counsel and investigative services to advance the claim to conclusion. - Maintain an ongoing diary. - Continually assess exposure and evaluate for accurate reserves and settlement recommendations. - Prepare Loss Reports providing thorough analysis of liability and damages. - Where applicable, determine if subrogation and/or risk transfer exists and initiate recovery efforts at the direction of the client. - Document all correspondence, reports, discussions and decisions in the claim file record. - Provide outstanding service to the client. - Assist Supervisors and Claim Department with requested tasks or special projects. - Other duties as assigned. Qualifications - High School Diploma or GED required; bachelor’s degree in related field (preferred) and a minimum of seven+ (7) years’ commercial auto and general liability casualty related experience; or equivalent combination of advanced education and experience. - At least 10 years of Commercial Automobile and General Liability claims experience required. - Knowledge of claims handling concepts, practices, and techniques, including but not limited to coverage issues and product line knowledge. - Demonstrated verbal and written communications skills. - Demonstrated advanced analytical, decision-making and negotiation skills. - Computer proficiency. Preferred Skills - Ability to communicate effectively and clearly, both orally and in writing. - Ability to manage relationships in a fast-paced environment, while demonstrating problem-solving and decision-making skills to work with customers. - Good analytical abilities to review, exercise judgment and evaluate claims to make sound decisions with a minimal amount of supervision. - Excellent customer service skills. - An understanding of the litigation process and case valuation in multiple jurisdictions. - Ability to carry out detailed written or verbal instructions, respond to requests effectively and efficiently, and exhibit good common sense. - An ability to handle assigned claims following company guidelines and industry best practices with a minimal amount of supervision. - Time management skills, organizational skills and ability to prioritize issues and tasks. - Ability to effectively operate computer equipment and applications. - Independence, flexibility, and creativity. Other Qualifications - Multi-state adjuster licensure within home state or designated state and/or the ability to obtain licenses through home state reciprocity or through state adjuster examinations. - AICPCU industry designation. Mental and Physical Requirements - Mental Effort: - Follow one- or two-step instructions; routine, repetitive tasks. - 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. - Logical or scientific thinking to solve problems; several abstract and concrete variables. - Wide range of intellectual and practical problems; comprehend most obscure concepts. - Mathematical Development: - Simple addition and subtraction; copying figures, counting, and recording. - Add, subtract, multiply, and divide whole numbers. - 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. - 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. - Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence. - Ability to compose original correspondence, follow technical manuals, and have increased contact with people. - Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures. - Physical Effort: - 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.

Role Description The medical case manager provides telephonic case management in a workers’ compensation environment coordinating resources and cost-effective options on a case-by-case basis to facilitate quality individualized treatment goals and return to work placement. Essential Duties and Responsibilities - Possess excellent communication and organizational skills to interface with the client, claimants, and staff. - Work well independently and set priorities. - Provide telephonic outreach for assessment and follow-up for case communication and coordination to include assessing, planning, implementing, and coordinating care. - Conduct and document initial assessment with the injured worker, employer, and provider and maintain regular contact with all parties involved to facilitate communication and to formulate a clinical case plan. - Responsible for coordination of contact with provider, claimant, RTW contact, and claims examiner. - Review case records and reports, collect and analyze data, evaluate client's medical status, and define needs and problems in order to provide proactive case management services. - Assessment of medical records for appropriateness of treatment and level of care being provided. Referral to the Medical Director if appropriate within the established timeframes. - Facilitate timely return to work date coordinating RTW with the claimant, employer, and physicians. - Maintain contact and communicate updated activity with all parties involved with the case. - Telephonically monitor medical appointments of the injured worker to address RTW, current treatment plan, and identify potential issues and promote positive treatment outcomes. Negotiate treatment plan with treating physician. Additional Functions and Responsibilities - Demonstrates ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards. - Maintain minimum billing and established template documentation standards adhering to URAC standards and company policy and procedures. - Reporting billing hours in accordance with case activity and billing practices. - Maintain confidentiality - Knowledge of laws and regulations pertaining to HIPAA and PHI. - Other job duties as assigned. Qualifications - Diploma, Associate or Bachelor’s degree in Nursing, Master’s level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferred. - Current, unrestricted Registered Nurse (RN), Licensed Practical Nurse (LPN), and/or Certified Case Manager (CCM) license required. - CCM, CMCN, CPHUR, CPDM, COHN, or CDMS certification preferred. Experience - Three or more years of diverse clinical experience in acute care. - Two or more years of medical case management or managed care experience, Worker’s Compensation background preferred. - Knowledge of utilization management, quality improvement, discharge planning, and/or cost management. - Ability to solve practical problems and deal with a variety of variables. - Possess planning, organizing, conflict resolution, negotiating, and interpersonal skills. - Excellent interpersonal skills and excellent organizational skills. - Ability to set priorities and work independently is essential. - Proficient with Microsoft Office applications including Word, Excel, and PowerPoint. Equipment Operated/Used - Essential Equipment: Desk, Telephone/Fax, Computer Keyboard, Mouse, System Applications. - Essential Tools: Pens, pencil, computer, Keyboard. - Essential Vehicles: N/A. Special Equipment or Clothing - Professional attire adhering to the Company Dress Code. Mental and Physical Requirements - Mental Effort: - 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. - Logical or scientific thinking to solve problems; several abstract and concrete variables. - Wide range of intellectual and practical problems; comprehend most obscure concepts. - Mathematical Development: - Simple addition and subtraction; copying figures, counting, and recording. - Add, subtract, multiply, and divide whole numbers. - 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. - 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. - 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 Effort - 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. - 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. - Visual Requirements necessary to perform the job: - Far vision: clarity of vision at 20 feet or more. - Near vision: clarity of vision at 20 inches or less. - 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.

Role Description Responsible for the prompt review of policy information to determine coverage for loss/damage/injury. Conduct an efficient claim examination and investigation leading to the final resolution of liability claims, including matters in litigation. Frequent contact and interaction with involved parties including claimants and their legal representatives will be required. Recommendations regarding loss exposure and associated reserve and settlement strategy will be effectively communicated to the client. Duties and Responsibilities - Review and interpret coverage, process, and conclude assigned claims including investigation and evaluation of Auto and/or General Liability Property Damage and Bodily Injury Casualty Claims in multiple jurisdictions. - Oversee and direct outside investigative service providers and work closely with the client and client counsel and investigative services to advance the claim to conclusion. - Maintain an ongoing diary. - Continually assess exposure and evaluate accurate reserves and settlement recommendation. - Prepare Loss Reports providing thorough analysis of coverage, liability, and damages. - Where applicable, determine if subrogation and/or risk transfer exists and initiate recovery efforts in the direction of the client. - Document all correspondence, reports, discussions, and decisions in the claim file record. - Provide outstanding service to the client. Qualifications - High School Diploma or GED required; bachelor’s degree in related field (preferred) and three years auto and general liability casualty related experience; or equivalent combination of advanced education and experience. - At least three years of Automobile and General Liability claims experience required. - Knowledge of claims handling concepts, practices, and techniques, including but not limited to coverage issues, litigation management and product line knowledge. - Demonstrated verbal and written communications skills. - Demonstrated advanced analytical, decision-making and negotiation skills. - Computer proficiency. Preferred Skills - Ability to communicate effectively and clearly, both orally and in writing. - Ability to manage relationships in a fast-paced environment, while demonstrating problem solving and decision-making skills to work with customers. - Good analytical abilities to review, exercise judgment and evaluate claims to make sound decisions with a minimal amount of supervision. - Excellent customer service skills. - An understanding of the litigation process and case valuation in multiple jurisdictions. - Ability to carry out detailed written or verbal instructions, ability to respond to requests effectively and efficiently and exhibit good common sense. - An ability to handle assigned claims following company guidelines and industry best practices with a minimal amount of supervision. - Time management skills, organizational skills, and ability to prioritize issues and tasks. - Ability to effectively operate computer equipment and applications. - Independence, flexibility, and creativity. Other Qualifications - Multiple Adjuster licenses are preferred but candidate must have a New York State Adjuster License. Mental and Physical Requirements - Mental Effort: - 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. - Logical or scientific thinking to solve problems; several abstract and concrete variables. - Wide range of intellectual and practical problems; comprehend most obscure concepts. - Mathematical Development: - Simple addition and subtraction; copying figures, counting, and recording. - Add, subtract, multiply, and divide whole numbers. - 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. - 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. - Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence. - Ability to compose original correspondence, follow technical manuals, and have increased contact with people. - Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures. - Physical Effort: - 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. - Near vision: clarity of vision at 20 inches or less. - Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet.

Role Description Responsible for the prompt review of policy information to determine coverage for loss/damage/injury. Conduct an efficient claim examination and investigation leading to the final resolution of liability claims, including matters in litigation. Frequent contact and interaction with involved parties including claimants and their legal representatives will be required. Recommendations regarding loss exposure and associated reserve and settlement strategy will be effectively communicated to the client. Duties and Responsibilities - Review and interpret coverage, process, and conclude assigned claims including investigation and evaluation of Auto, No Fault PIP, and/or General Liability Casualty Claims in the jurisdiction of NY. - Oversee and direct outside investigative service providers and work closely with the client and client counsel and investigative services to advance the claim to conclusion. - Maintain an ongoing diary. - Continually assess exposure and evaluate for accurate reserves and settlement recommendation. - Prepare Loss Reports providing thorough analysis of coverage, liability, and damages. - Where applicable, determine if subrogation and/or risk transfer exists and initiate recovery efforts at the direction of the client. - Document all correspondence, reports, discussions, and decisions in the claim file record. - Provide outstanding service to the client. Qualifications - High School Diploma or GED required; bachelor’s degree in related field (preferred) and three (3) years auto and general liability casualty and or No Fault/PIP related experience; or equivalent combination of advanced education and experience. - At least two years of Automobile and General Liability claims experience required. - Knowledge of claims handling concepts, practices, and techniques, including but not limited to coverage issues, litigation management and product line knowledge. - Demonstrated verbal and written communications skills. - Demonstrated advanced analytical, decision-making and negotiation skills. - Computer proficiency. Preferred Skills - Ability to communicate effectively and clearly, both orally and in writing. - Ability to manage relationships in a fast-paced environment, while demonstrating problem solving and decision-making skills to work with customers. - Good analytical abilities to review, exercise judgment and evaluate claims to make sound decisions with a minimal amount of supervision. - Excellent customer service skills. - An understanding of the litigation process and case valuation in multiple jurisdictions. - Ability to carry out detailed written or verbal instructions, ability to respond to requests effectively and efficiently and exhibit good common sense. - An ability to handle assigned claims following company guidelines and industry best practices with a minimal amount of supervision. - Time management skills, organizational skills, and ability to prioritize issues and tasks. - Ability to effectively operate computer equipment and applications. - Independence, flexibility, and creativity. Other Qualifications - Candidate must have a New York State Adjuster License. Mental and Physical Requirements - Mental Effort: - 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. - Logical or scientific thinking to solve problems; several abstract and concrete variables. - Wide range of intellectual and practical problems; comprehend most obscure concepts. - Mathematical Development: - Simple addition and subtraction; copying figures, counting, and recording. - Add, subtract, multiply, and divide whole numbers. - 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. - 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. - Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence. - Ability to compose original correspondence, follow technical manuals, and have increased contact with people. - Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures. Physical Effort - 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. - Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling. - Grasping: Applying pressure to an object with the fingers and palm. Working Conditions - No specific working conditions mentioned.

Role Description The medical case manager provides telephonic case management in a workers' compensation environment, coordinating resources and cost-effective options on a case-by-case basis to facilitate quality individualized treatment goals and return to work placement. Essential Duties and Responsibilities - Possess excellent communication and organizational skills to interface with the client, claimants, and staff. - Work well independently and set priorities. - Provide telephonic outreach for assessment and follow-up for case communication and coordination, including: - Assessing, planning, implementing, and coordinating care. - Conducting and documenting initial assessment with the injured worker, employer, and provider. - Maintaining regular contact with all parties involved to facilitate communication and formulate a clinical case plan. - Responsible for coordination of contact with provider, claimant, RTW contact, and claims examiner. - Review case records and reports, collect and analyze data, evaluate client's medical status, and define needs and problems to provide proactive case management services. - Assessment of medical records for appropriateness of treatment and level of care being provided; referral to the Medical Director if appropriate within the established timeframes. - Facilitate timely return to work date coordinating RTW with the claimant, employer, and physicians. - Maintain contact and communicate updated activity with all parties involved with the case. - Telephonically monitor medical appointments of the injured worker to address RTW, current treatment plan, identify potential issues, and promote positive treatment outcomes. - Negotiate treatment plan with treating physician. Additional Functions and Responsibilities - Demonstrates ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards. - Maintain minimum billing and established template documentation standards adhering to URAC standards and company policy and procedures. - Reporting billing hours in accordance with case activity and billing practices. - Maintain confidentiality - Knowledge of laws and regulations pertaining to HIPAA and PHI. - Other job duties as assigned. Equipment Operated/Used - Essential Equipment: Desk, Telephone/Fax, Computer Keyboard, Mouse, System Applications. - Essential Tools: Pens, pencil, computer, Keyboard. - Essential Vehicles: N/A. Special Equipment or Clothing - Professional attire adhering to the Company Dress Code. Qualifications - Three or more years of diverse clinical experience in caring for acutely ill patients with multiple disease conditions. - Three or more years of Managed Care and/or Worker's Compensation experience. - Knowledge of utilization management, quality improvement, discharge planning, and cost management. - Background in state worker's compensation law and practices desirable. - Ability to solve practical problems and deal with a variety of variables. - Possess planning, organizing, conflict resolution, and negotiating skills. - Excellent interpersonal skills and excellent organizational skills. - Proficient with Microsoft Office applications including Word, Excel, and PowerPoint. Education - Diploma, associate or bachelor’s degree in nursing, Master's level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferred. - Current, unrestricted RN license required. - CCM, CPDM, COHN or CDMS certification preferred.

Role Description Responsible for the prompt review of policy information to determine coverage for loss/damage/injury. Conduct an efficient claim examination and investigation leading to the final resolution of liability claims, including matters in litigation. Frequent contact and interaction with involved parties including claimants and their legal representatives will be required. Recommendations regarding loss exposure and associated reserve and settlement strategy will be effectively communicated to the client. Duties and Responsibilities - Review and interpret coverage, process, and conclude assigned Personal Injury Protection (PIP) claims including investigation and evaluation of Auto and/or General Liability Casualty Claims in the jurisdiction of NY and NJ. - Respond to PIP Arbitration Proceedings. - Oversee and direct outside investigative service providers and work closely with the client and client counsel and investigative services to advance the claim to conclusion. - Maintain an ongoing diary. - Continually assess exposure and evaluate accurate reserves and settlement recommendation. - Prepare Loss Reports providing thorough analysis of coverage, liability, and damages. - Where applicable, determine if subrogation and/or risk transfer exists and initiate recovery efforts in the direction of the client. - Document all correspondence, reports, discussions, and decisions in the claim file record. - Provide outstanding service to the client. Qualifications - High School Diploma or GED required; bachelor’s degree in related field (preferred) and three years auto and general liability casualty related experience; or equivalent combination of advanced education and experience. - At least three years of Automobile and General Liability claims experience required. - Knowledge of claims handling concepts, practices, and techniques, including but not limited to coverage issues, litigation management and product line knowledge. - Demonstrated verbal and written communications skills. - Demonstrated advanced analytical, decision-making and negotiation skills. - Computer proficiency. Preferred Skills - Ability to communicate effectively and clearly, both orally and in writing. - Ability to manage relationships in a fast-paced environment, while demonstrating problem solving and decision-making skills to work with customers. - Good analytical abilities to review, exercise judgment and evaluate claims to make sound decisions with a minimal amount of supervision. - Excellent customer service skills. - An understanding of the litigation process and case valuation in multiple jurisdictions. - Ability to carry out detailed written or verbal instructions, ability to respond to requests effectively and efficiently and exhibit good common sense. - An ability to handle assigned claims following company guidelines and industry best practices with a minimal amount of supervision. - Time management skills, organizational skills, and ability to prioritize issues and tasks. - Ability to effectively operate computer equipment and applications. - Independence, flexibility, and creativity. Other Qualifications - Candidate must have a New York State Adjuster License. Mental and Physical Requirements - Mental Effort: - 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. - Logical or scientific thinking to solve problems; several abstract and concrete variables. - Wide range of intellectual and practical problems; comprehend most obscure concepts. - Mathematical Development: - Simple addition and subtraction; copying figures, counting, and recording. - Add, subtract, multiply, and divide whole numbers. - 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. - 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. - 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 Effort: - 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. - Near vision: clarity of vision at 20 inches or less. - Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet.