Claims Adjuster

SPECIFICATIONS AND REQUIREMENTS

CLAIMS ADJUSTER

GENERAL DUTIES AND RESPONSIBILITIES:

Reviews and analyzes reports of accidents including property damage and bodily injury to determine liability; reviews and analyzes Liability and/or Workers Compensation claims and recommends appropriate action.

Consults on injury cases with various medical personnel in order to ascertain the extent and cost of treatment loss of earning capacity and prognosis; confers with County physician on employment limitations.

Performs the calculation and payment of benefits whether indemnity and/or medical benefits including entering all payments for benefits.

Coordinates the gathering of formal evidence by taking photographs preparing diagrams and making measurements at accident scene; arranges for witnesses to appear at legal proceedings and prepares accident reports.

For Workers Compensation claims the adjuster will contact the injured employee employer and medical provider to document the claim.

For Liability claims the adjuster will contact the claimant the division and any witnesses.

Contacts injured employee employer and medical provider to document claim. Conducts field investigations face-to-face statements with employees employer representatives and witnesses to understand the nature of the claim and gain an understanding of what occurred prior to the claim.

Negotiate claim settlements with the Director of Risk Management the County Administrator the County Attorney claimants and/or their legal teams. Attend mediations with the County Attorneys office to support the claims process.

Provide advice regarding potential fraud subrogation and underwriting/safety risk and communication with counsel.

Authorizes/coordinates medical treatment with walk-in facilities and specialists to update claim.

Analyze complex information from different sources such as police reports videos from surveillance cameras or audio and other information to further understand the incident.

Make decisions for approvals of medical treatments and property restoration. Make determinations on liability or compensability for Workers Compensation claims. Apportion percentage of liability and negotiate settlement with claimant or claimants attorney or Liability Claims.

Review police reports medical treatment records medical bills or physical property damage to
determine the extent of liability.

Investigates liability claims inputs data into the system association with findings.

Calculates/processes timely disability benefits and impairment ratings of 1% or more when given to
issue benefits to avoid penalties.

Processes outgoing letters to injured employees and medical providers and places them on notice of
action taking place.

Sets up medical only claims to document/update current work status and treatment.

Monitors/obtains discharge papers for impairment ratings and issues benefits when owed and paid
within mandated timeframe to avoid penalties.

Monitors work status for a disability of 7 days or less through discharge for closing a claim.

Processes employee-received notices of outstanding medical bills to resolve non-payment issues.

Reviews/corrects reporting by Center for Medicare/Medicaid Services (CMS) for accuracy.

Denies/processes claims for non-work-related injuries with timely electronic filing to avoid penalties.

The Workers Compensation Adjuster calculates/processes disability benefits for impairment ratings of 1% or more when issuing benefits to avoid penalties. Sets up medical claims to document/update current work status and treatment. Monitors/obtains medical records and work status to ensure timely calculation and payment of indemnity and impairment ratings complete State EDI mandated reporting within regulated time frames to avoid penalties. Processes employee-received notices of outstanding medical bills to resolve non-payment issues.

Reviews/corrects reporting by Center of Medicare/Medicaid Services (CMS) for accuracy.

For disability more than 8 days initiates timely electronic filings to Division of Workers Compensation.

Conducts recorded interviews with employees and witnesses.

Attends meetings with other Divisions Professional Standards/Human Rights Section (PS/HRS) and Human Resources to discuss complex claims. Performs related work as assigned.