Professional Liability Claims Examiner III – Team Leader

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $100k - $112k / year

⏰ Full Time

🟠 Senior

📋 Claims Specialist

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TRISTAR Insurance Group

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1987

💼 Consulting

🏥 Healthcare

📦 Logistics

Consulting • Healthcare • Logistics

TRISTAR Insurance Group is a national third-party administrator (TPA) that provides insurance administration and risk management services to employers, insurers and public entities. Its solutions include property & casualty, workers' compensation, general and auto liability, managed care (bill review, case management, utilization review, nurse triage, pharmacy benefit management), absence and disability management, employee group benefits administration, and risk control and workplace safety services. TRISTAR emphasizes collaborative, technology-enabled and tailored services to transform risk into opportunity for its clients.

📋 Description

• Provide day-to-day guidance, technical support, and work direction to Claims Examiners assigned to the NVA Team • Manage an active caseload of approximately 150–165 Professional Liability claims • Conduct timely and thorough investigations, gathering and evaluating documentation, evidence, statements, and other information • Review and interpret applicable policies, endorsements, coverage provisions, and relevant laws to determine coverage, liability, damages, and claim-handling strategies • Communicate with clients, claimants, legal counsel, service providers, vendors, and other involved parties regarding claim status and resolution • Establish and maintain accurate reserves within assigned authority and company and client guidelines • Review and approve authority requests submitted by assigned Claims Examiners within delegated authority levels • Negotiate, settle, and finalize assigned claims within delegated authority levels • Maintain an effective diary system, complete timely case reviews, and document claim activity, evaluations, decisions, communications, and action plans • Communicate significant claim developments, coverage concerns, litigation issues, exposure changes, and recommended strategies to the Claims Supervisor, Area Manager, and client • Conduct independent claim-file reviews for claim-handling quality, reserve accuracy, documentation, compliance, and adherence to action plans • Assist with training, coaching, and mentoring Claims Examiners and provide feedback on technical development and work quality • Identify and escalate workflow concerns, quality issues, client-service matters, and operational risks • Comply with applicable laws, regulations, company policies, client service instructions, and claim-handling procedures • Perform other duties as assigned

🎯 Requirements

• Bachelor’s degree in a related field (preferred) • Three (3) or more years of related experience, or equivalent combination of education and experience • Technical knowledge of coverage, statutory regulations, and medical terminology • Analytical skills • Excellent written and verbal communication skills, including 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) • Active Independent Adjuster New York State License • High School Diploma or GED is listed as the education level