Claims Adjuster

Summary

Reports directly to the unit Claims Supervisor and may be called upon to provide technical backup in the absence of the Claims Supervisor.

In accordance with applicable statutes and in keeping with company rules, regulations, and established performance objectives, is responsible for effectively managing to conclusion an assigned inventory of claim files that may include cases of extreme complexity or with unique or unusual issues.

Essential Duties and Responsibilities

• Perform a three-point contact on all new losses within 24 hours of receipt of the claim to include the claimant, employer, and treating physician to document relevant facts surrounding the incident itself as well as disability and treatment status.
• Thoroughly and accurately document ongoing case facts and relevant information necessary for establishing compensability, the need for disability payments, the use of vendors, medical and expense payments, and what is being done to move the case toward closure.
• Assure that all assigned indemnity claims have an up to date plan of action outlining activities and actions anticipated for ultimately resolving the claim.
• Form a partnership with the medical case manager to maximize early return to work potential thereby reducing the need for extended disability payments, vocational rehabilitation, and other protracted claims costs.
• Initiate the referral to the SIU of cases with suspected fraud.
• Aggressively pursue subrogation from culpable third parties, contributions on multiple defendant cases, and apportionment when there is pre-existing disability.
• Assure that the claim file is handled totally in accordance with applicable statutes as well as in-force service contracts and company guidelines.
• Review and approve all vocational rehabilitation plans.
• Establish, monitor, and adjust monetary case reserves when warranted and in strict accordance with assigned authority levels.
• Review all medical bills for appropriateness prior to referral to InterMed for payment and posting to the claim file.
• Exhibit and maintain a courteous and helpful attitude and project a professional image on behalf of the company.
• Respond to telephone messages and inquiries within 24 hours of receipt and to written inquiries within one week of receipt.
• Requires a working knowledge of the Labor Code of the State of California as it pertains to workers compensation claims and the legal requirements for handling them.
• Litigation management - Direct, manage, and control the litigation process.
• Handles other duties and tasks as deemed appropriate by the Supervisor or Manager.

Qualification Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required.

Education and / or Experience

Bachelor's degree (B. A.) from four-year college or university; at least seven years related experience and / or training;

or equivalent combination of education and experience. Requires a high degree of claims handling expertise to include a minimum of at least five years experience managing indemnity cases, many with complex or high potential subrogation, rehabilitation, medical management, and / or legal issues & possess an SIP certificate.

Certificates and Licenses

Active study for the IEA Certificate and Self-Insured Certificate, and successful completion of, or active study for the WCCP designation, or the equivalent in related studies or work experience.

Last updated : 2024-04-19