claims examiner

POINT C

<div><div>Point C is a National third-party administrator (TPA) with local market presence that delivers customized self-funded benefit programs. Our commitment and partnership means thinking beyond the typical solutions in the market &ndash; to do more for clients &ndash; and take them beyond the standard &quot;Point A to Point B.&quot; We have researched the most effective cost containment strategies and are driving down the cost of plans with innovative solutions such as, network and payment integrity, pharmacy benefits and care management. There are many companies with a mission. We are a mission with a company.</div>
Point C is looking for a detail-oriented and motivated Claims Examiner to join our team. In this role, you'll be responsible for accurately processing medical claims while ensuring compliance with plan documents, policies, and industry regulations. The ideal candidate is analytical, organized, and experienced in self-funded or third-party administration environments.

Primary Responsibilities
<ul>
<li>Adjudicate new claims and process adjustments, including denials upon receipt of additional information</li>
<li>Review and resolve appeals and subrogation/third-party liability cases</li>
<li>Manage individual inventory to ensure timely turnaround and production goals are met</li>
<li>Ensure claims are processed in accordance with stop loss contract terms</li>
<li>Respond to internal and external inquiries via email and other channels within established timeframes</li>
<li>Follow up on missing or incomplete information to ensure claims can be accurately processed</li>
<li>Maintain minimum production, financial, and procedural accuracy standards on a monthly basis</li>
</ul>
Qualifications
<ul>
<li>Experience with Third Party Administrator (TPA) or self-funded claims administration preferred</li>
<li>1-2 years of experience in insurance claims processing required</li>
<li>Experience reviewing and finalizing claim payments for accuracy in accordance with plan policies</li>
<li>Ability to interpret and apply plan documents to ensure accurate claims adjudication</li>
<li>Experience with VBA systems preferred</li>
<li>Working knowledge of CPT and ICD-10 coding</li>
<li>Basic understanding of medical terminology</li>
<li>Strong communication and customer service skills</li>
<li>Proficiency in Microsoft Office and general computer applications</li>
<li>Ability to maintain confidentiality and comply with all company policies and procedures</li>
<li>Able to work independently with minimal supervision</li>
<li>Ability to prioritize, multitask, and work overtime as needed</li>
<li>Associate Degree Preferred</li>
</ul><div><div>Benefits:</div>
<ul><li>Comprehensive medical, dental, vision, and life insurance coverage</li>
<li>401(k) retirement plan with employer match</li>
<li>Health Savings Account (HSA) &amp; Flexible Spending Accounts (FSAs)</li>
<li><div>Paid time off (PTO) and disability leave</div>
</li><li>Employee Assistance Program (EAP)</li></ul> 


Equal Employment Opportunity: At Point C Health, we know we are better together. We value, respect, and protect the uniqueness each of us brings. Innovation flourishes by including all voices and makes our business&mdash;and our society&mdash;stronger. Point C Health is an equal opportunity employer and we are committed to providing equal opportunity in all of our employment practices, including selection, hiring, performance management, promotion, transfer, compensation, benefits, education, training, social, and recreational activities to all persons regardless of race, religious creed, color, national origin, ancestry, physical disability, mental disability, genetic information, pregnancy, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, and military and veteran status, or any other protected status protected by local, state or federal law.</div></div>

Claims Examiner

TEEMA Group

<div>Claims Examiner III &ndash; Workers&rsquo; Compensation
Role Summary
The Claims Examiner III is responsible for independently managing the full lifecycle of Workers&rsquo; Compensation indemnity claims, from initial reporting through final resolution. Operating with minimal supervision, this role requires strong analytical judgment, regulatory knowledge, and a commitment to delivering timely, accurate, and compliant claim outcomes.
This position plays a critical role in supporting employers and injured employees by ensuring claims are handled with professionalism, urgency, and integrity. The ideal candidate is organized, service-oriented, and confident in navigating complex claim scenarios within established authority levels and statutory guidelines.
This is an excellent opportunity for an experienced claims professional seeking autonomy, responsibility, and meaningful impact in a structured and collaborative office environment.
Duties &amp; Responsibilities<ul><li>
Manage loss-time Workers&rsquo; Compensation claims within Texas jurisdiction from inception through closure</li><li>
Investigate, evaluate, and determine compensability in accordance with statutory regulations and internal guidelines</li><li>
Administer and issue benefit payments accurately and within required timelines</li><li>
Ensure compliance with all applicable state laws, regulatory standards, and client-specific handling instructions</li><li>
Prepare detailed, formal captioned reports that meet client documentation requirements</li><li>
Communicate effectively and professionally with clients, claimants, employers, attorneys, and internal stakeholders</li><li>
Provide exceptional customer service while assisting employers and injured employees in understanding the Workers&rsquo; Compensation process</li><li>
Maintain organized, accurate claim files and documentation</li><li>
Demonstrate strong time management and sense of urgency in claim handling</li><li>
Collaborate with management and fellow claims professionals to ensure consistent, high-quality outcomes</li><li>
Consistently maintain on-site office attendance in a timely manner to support team operations and client engagement</li><li>
other duties as assigned</li></ul>
Required Qualifications<ul><li>
High School Diploma or GED required</li><li>
Minimum five (5) years of related Workers&rsquo; Compensation claims handling experience, or equivalent combination of education and experience</li><li>
Current Texas Workers&rsquo; Compensation Adjuster License</li><li>
Strong knowledge of Texas Workers&rsquo; Compensation statutes and indemnity claim handling</li><li>
Ability to manage claims independently with minimal supervision</li><li>
Excellent written and verbal communication skills</li><li>
Strong organizational skills and attention to detail</li><li>
Professional demeanor with a positive, team-oriented attitude</li><li>
Ability to interact effectively with clients, claimants, and internal teams</li></ul>
Desired Qualifications<ul><li>
Bachelor&rsquo;s degree in Business, Risk Management, Insurance, or related field (preferred)</li><li>
Experience handling complex or high-exposure indemnity claims</li><li>
Demonstrated ability to prepare formal client-ready reports</li><li>
Proven track record of delivering high-quality customer service</li><li>
Strong problem-solving and decision-making skills</li></ul>
About the Organization
This organization is a professional risk management and claims administration firm committed to delivering responsive, compliant, and high-quality claims services. The culture emphasizes accountability, collaboration, and client satisfaction while empowering employees with the autonomy and support needed to succeed.
Location &amp; Work Type
On-site position in an office environment.
Full-time, exempt role. Regular in-office attendance is required due to the collaborative and client-facing nature of the position.
#Workwolf</div>

Claims Examiner III

Wellington Insurance Group

As a Claims Examiner II at Wellington, you would be responsible for investigating, evaluating, negotiating, and resolving personal lines property claims (homeowner). You would also be responsible for adjusting major and complex losses in their entirety. You may also adjust standard losses.**This role requires on-site attendance in Fort Worth, Texas**Responsibilities<ul><li>Responsible for completing coverage investigations and coverage analysis and develop a detailed resolution plan.</li><li>Responsible for providing exceptional customer service and handles claims in accordance with prescribed authority and best claims practices.</li><li>Develop relationships with customers via telephone, investigate insurance policy coverage, determine cause of loss, and document activity on each claim to come to a resolution quickly and accurately.</li><li>Identify, analyze, and resolve coverage issues according to established Company protocol, including thorough policy review and analysis of application to the individual claim. With supervisor approval, negotiate with policyholders to settle claims of limited monetary value.</li><li>Develop and direct investigative plans. Conduct timely and detailed investigations that include scene investigation (e.g., photos, diagrams, blueprints, maps), statements, official reports (e.g., police, fire, weather, hail), and ownership documents (e.g., tax liens, judgments, encumbrances). Identify alleged and actual damages, identify potential liable parties, recognize and address potential fraud.</li><li>Conduct thorough damage development, leading to timely and adequate evaluations, including appraisals/estimates, business records, invoices, detailed inventory, purchase records, receipts, credit card statements, and ALE documents. Develop appropriate methods of repair/replacement, verify ownership, and apply any special limitations.</li><li>Establish voice to voice communication within 24 hours. Maintain effective communications with the Customer at all times. Consistently work within specific time limits and authority.</li><li>Maintain company reputation and integrity of insurance products by complying with federal and state regulations, Company protocol, and service standards. Maintain current knowledge of regulations and issues, industry activity, and trends.</li><li>Partner with SIU and Subrogation to identify questionable claims and subrogation opportunities. Assist or prepare files for suit, trial, or subrogation.</li></ul>Qualifications<ul><li>Two years of related, applicable experience.</li><li>Associates degree (A.A. or A.S.) or equivalent from a two-year college, business school, or technical school.</li><li>Adjusters License for states in which the Company conducts business.</li><li>Bilingual with the ability to translate documents and verbal messages from English to Spanish (and vice versa) preferred but not required.</li></ul>Wellington is an Equal Opportunity Employer and considers all qualified applicants regardless of race, gender, color, religion, national origin, age, sexual orientation, gender identity, disability, veteran status or other classification protected by law.Job Type: Full-timeBenefits:<ul><li>401(k)</li><li>401(k) matching</li><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Ability to Commute:<ul><li>Fort Worth, TX 76116 (Required)</li></ul>Ability to Relocate:<ul><li>Fort Worth, TX 76116: Relocate before starting work (Required)</li></ul>Work Location: In person

Claims Examiner - II

TEEMA

<div><h2 class="jobSectionHeader">Senior Workers&rsquo; Compensation Claims Examiner (Texas Licensed)</h2>
We are seeking an experienced Workers&rsquo; Compensation Claims Examiner to join a collaborative claims team handling complex indemnity claims from initial investigation through resolution. This is an excellent opportunity for a detail-oriented professional who thrives in a fast-paced environment and enjoys balancing analytical decision-making with strong client and claimant communication.
In this role, you will independently manage a caseload of approximately 110&ndash;150 workers&rsquo; compensation claims, including complex files requiring advanced investigation, compensability analysis, reserve management, and ongoing medical oversight. You will work closely with claimants, employers, medical providers, attorneys, and internal stakeholders to ensure timely and compliant claim resolution in accordance with Texas workers&rsquo; compensation regulations.
Key Responsibilities:<ul><li>
Investigate and manage workers&rsquo; compensation claims from inception to closure</li><li>
Determine compensability and administer benefits in accordance with state laws and company guidelines</li><li>
Coordinate medical treatment and manage related billing activity</li><li>
Establish and maintain accurate claim reserves</li><li>
Maintain organized documentation and diary management for all claim activity</li><li>
Communicate effectively with clients regarding claim status, trends, and risk concerns</li><li>
Conduct independent file reviews and proactively drive claims toward resolution</li></ul>
Qualifications:<ul><li>
Active Texas Workers&rsquo; Compensation Adjuster License required</li><li>
5+ years of workers&rsquo; compensation claims handling experience, including complex indemnity claims</li><li>
Strong understanding of workers&rsquo; compensation statutes, medical terminology, and claims investigation</li><li>
Excellent written and verbal communication skills</li><li>
Ability to manage a high-volume caseload independently</li><li>
Proficiency with Microsoft Office applications preferred</li></ul>
This position offers the opportunity to join a professional, team-oriented environment where your expertise and judgment will have a direct impact on claim outcomes and client satisfaction.
#Workwolf</div>

Workers Compensation Claims Examiner

<div>Overview: 
We are seeking an experienced Workers&rsquo; Compensation Claims Examiner III to support a high-volume claims environment in Irving, TX. This is a fully on-site position requiring in-office attendance five (5) days per week with no hybrid or remote option available. Under minimal supervision, this role is responsible for managing all aspects of indemnity claims handling from inception through resolution, within established authority and regulatory guidelines. This position requires consistent in-office collaboration with internal staff, claimants, employers, and leadership to ensure timely and compliant claims administration. 
 
What you will be doing:<ul><li>
Manage Texas loss time Workers&rsquo; Compensation claims from inception to closure</li><li>
Investigate, evaluate, and determine compensability of claims</li><li>
Administer indemnity and medical benefits in compliance with TX statutory requirements</li><li>
Ensure claims handling aligns with internal Best Practices and client handling guidelines</li><li>
Prepare formal captioned reports in accordance with claim requirements</li><li>
Communicate professionally with claimants, employers, attorneys, and internal stakeholders</li><li>
Assist employers and employees in understanding the Workers&rsquo; Compensation claims process</li><li>
Maintain accurate documentation and ensure timely claims processing</li><li>
Provide high-quality customer service throughout the life of the claim</li><li>
Maintain strong organization and sense of urgency in a deadline-driven environment</li></ul>
What you must have:<ul><li>
Active Texas Workers&rsquo; Compensation Adjuster License</li><li>
Minimum of 5+ years of Texas Workers&rsquo; Compensation claims experience</li><li>
Experience managing public entity claims and First Responder claims</li><li>
Strong knowledge of Texas Workers&rsquo; Compensation laws and regulations</li><li>
Excellent written and verbal communication skills</li><li>
Ability to manage multiple claims in a fast-paced environment</li><li>
High School Diploma or GED required</li><li>
Bachelor&rsquo;s Degree in a related field preferred</li></ul>
Other Information: 
Work Environment 
This position requires:<ul><li>
Daily interaction with internal team members and external stakeholders</li><li>
Full-time, on-site attendance</li><li>
Ability to work collaboratively in a professional office setting</li><li>
Use of standard office equipment including computer, copier, and printer</li></ul>
Additional Requirements<ul><li>
Ability to pass background check and drug screening</li><li>
Authorized to work in the United States</li></ul> 
Salary/Rate Range: $36.53 &ndash; $38.46 per hour 
 
Term: 3-4 Month Contract (Potential Extension) 
If you are a talented, experienced Claims Adjuster/Examiner with an active Texas Workers Compensation license looking for a door into a large organization submit your resume now!
If you're interested, please reply to this advertisement or directly email your resume to me at DSalgado@teemagroup.com or by calling/texting (949) 295-5951.
I strive to reply within 48 hours. Looking forward to connecting with you soon. Thank you!
#Workwolf</div>

<div>Job Summary
Workers Compensation Claims Examiner III
TeemaGroup
Full-time- CONTRACT 3-4 months could be longer
In-Office | Irving, TX, United States<ul><li> 
POSITION SUMMARY: 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 in the office, in a timely manner, is inherently required of this position. 
 
DUTIES AND RESPONSIBILITIES: 
Handle loss time Workers&rsquo; Compensation claims in TX Office&mdash;Texas Jurisdiction 
Handle claims as per Best Practices, SOC 1 and client Claims Handling Instructions 
The ability to prepare a formal captioned report on claims meeting client requirements 
Well organized and CAN-DO attitude. 
Ability to effectively communicate in a professional manner 
Provide great customer service 
Assist employers and their employees understand the Workers&rsquo; Compensation process 
Investigate, evaluate, determine compensability, pay benefits timely as required and 
comply with all statutory requirements 
A good sense of urgency 
Ability to get along well with others with a positive attitude 
 
EQUIPMENT OPERATED/USED: Computer, 10-key, fax machine, copier, printer, and other office equipment. 
 
SPECIAL EQUIPMENT OR CLOTHING: Follow company dress code 
 
QUALIFICATIONS REQUIRED: 
 
Education/Experience: High School Diploma or GED required; Bachelor&rsquo;s degree in related field (preferred); five (5) or more years related experience; or equivalent combination of education and experience. 
 
Other Qualifications: 
Workers&rsquo; Compensation Adjusters License for the State of Texas</li></ul>
QUALIFICATIONS REQUIRED
Education &amp; Experience<ul><li>Claims Examiner II:</li><li>Bachelor&rsquo;s degree in a related field (preferred)</li><li>Claims Examiner III:</li><li>Minimum 5+ years of progressive workers&rsquo; compensation claims experience</li><li>Demonstrated experience handling complex and litigated indemnity claims</li></ul>
#Workwolf</div>

Workers Compensation Claims Examiner III

<div>Overview: 
Our client, the largest Third Party Administrator in North America is looking for an experienced Claims Adjuster to handle Workers Compensation Claims. At the direction of the Claims Supervisor and/or Claims Manager, the Claims Adjuster/Examiner II / III manages all aspects of workers&rsquo; compensation indemnity, medical-only, future medical, and litigated claims from inception through resolution, within established authority and company/client guidelines. This role requires frequent interaction with clients, claimants, medical providers, attorneys, vendors, nurse case managers, vocational case managers, and internal staff. The level of complexity, litigation exposure, settlement authority, and leadership responsibility will be commensurate with the examiner&rsquo;s experience and designation (Level II or Level III). 
 
What you will be doing: 
Applies to Examiner II &amp; III<ul><li>
Manage a full caseload of workers&rsquo; compensation claims, including complex indemnity claims.</li><li>
Initiate, conduct, and document timely and thorough claim investigations.</li><li>
Determine compensability and administer benefits in accordance with state laws, rules, and company/client handling instructions.</li><li>
Manage medical treatment and medical billing; authorize services as appropriate.</li><li>
Communicate effectively with claimants, medical providers, vendors, and clients regarding claim issues.</li><li>
Compute and set reserves in accordance with Company and Client guidelines.</li><li>
Maintain an organized diary system and document claim files to reflect status, strategy, and action plans.</li><li>
Settle and/or finalize claims and obtain appropriate settlement authority.</li><li>
Conduct scheduled file reviews and respond to client inquiries.</li><li>
Identify injury trends, safety concerns, and other claim-related issues and communicate proactively to clients.</li><li>
Adhere to all company policies, procedures, and best practices.</li><li>
Utilize office systems and technology efficiently to manage caseload responsibilities.</li><li>
Perform other related duties as assigned.</li></ul>
Advanced / Senior Responsibilities (Primarily Examiner III)<ul><li>
Manage very complex, catastrophic, and litigated indemnity claims from inception to conclusion.</li><li>
Refer cases to outside defense counsel and actively participate in litigation strategy, hearings, mediations, and settlements.</li><li>
Identify and manage:<ul><li>
Subrogation opportunities</li><li>
Apportionment potential</li><li>
Excess reporting criteria and reimbursement</li></ul></li><li>
Prepare and assist with state audits, regulatory reporting, and client-specific reporting requirements.</li><li>
Develop and execute proactive claim strategies to drive timely and cost-effective resolution.</li><li>
Conduct detailed client file reviews and participate in client meetings as needed.</li><li>
Mentor and provide technical guidance to less experienced Claims Examiners.</li><li>
Handle multi-jurisdictional workers&rsquo; compensation claims as assigned.</li></ul> 
What you will be doing: 
Education &amp; Experience 
Claims Examiner II:<ul><li>
Bachelor&rsquo;s degree in a related field (preferred)</li><li>
Minimum 3+ years of workers&rsquo; compensation claims experience, or equivalent combination of education and experience</li></ul>
Claims Examiner III:<ul><li>
Minimum 5+ years of progressive workers&rsquo; compensation claims experience</li><li>
Demonstrated experience handling complex and litigated indemnity claims</li></ul>
Knowledge, Skills &amp; Abilities<ul><li>
Strong technical knowledge of workers&rsquo; compensation statutes, regulations, and medical terminology</li><li>
Ability to independently analyze and manage complex claims</li><li>
Excellent written and verbal communication skills</li><li>
Ability to convey technical information to claimants, clients, and internal stakeholders</li><li>
Strong organizational, analytical, and time-management skills</li><li>
Ability to interact professionally with individuals at all levels of the business environment</li><li>
Proficiency in Microsoft Word and Excel (preferred)</li></ul>
Certifications / Licenses<ul><li>
Hawaii Workers Compensation Adjusters License</li></ul> 

#Workwolf</div>

Workers Compensation Claims Examiner II/III - Hybrid

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