Workers Compensation Claims Adjuster Iii

Description:

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:

• Review all medical bills for appropriateness prior to referral to InterMed for payment and posting to the claim file.
• Initiate the referral to the SIU of cases with suspected fraud.
• Assure that the claim file is handled totally in accordance with applicable statutes as well as in-force service contracts and company guidelines.
• Handles other duties and tasks as deemed appropriate by the Supervisor or Manager.
• 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.
• Aggressively pursue subrogation from culpable third parties, contributions on multiple defendant cases, and apportionment when there is pre-existing disability.
• Assure that all assigned indemnity claims have an up to date plan of action outlining activities and actions anticipated for ultimately resolving the claim.
• Review and approve all vocational rehabilitation plans.
• 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.
• Establish, monitor, and adjust monetary case reserves when warranted and in strict accordance with assigned authority levels.
• Respond to telephone messages and inquiries within 24 hours of receipt and to written inquiries within one week of receipt.
• Exhibit and maintain a courteous and helpful attitude and project a professional image on behalf of the company.
• Litigation management - Direct, manage, and control the litigation process.
• 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.
• 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.

Requirements:

Competency:

To perform the job successfully, an individual should demonstrate the following competencies:

• Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Uses reason even when dealing with emotional topics.
• Interpersonal - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
• Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Responds to requests for service and assistance; Meets commitments.
• Team Work - Supports everyone's efforts to succeed.

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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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.