Claims Adjuster I/ii

County of Riverside
$72,758 - $121,555 Per year CA Riverside County Human Resources, 4080 Lemon St # 3rd, Riverside, CA 92501, United States Apply before 5/19/2024 11:59
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Overview

ABOUT THE POSITION

The County of Riverside’s Human Resources Department is seeking a Claims Adjuster I/II to support the Workers' Compensation Division. 

This position will carry a caseload of workers' compensation claims and will be responsible for establishing contact with injured workers, conducting Arising Out of Employment (AOE) and Course of Employment (COE) investigations, and determining if the injuries or illnesses are compensable. The Claims Adjuster II will also review claims for subrogation, prepare settlement documents, and calculate and approve benefit payments. 


Positions in this class series report to the Workers' Compensation Officer and are characterized by responsibility to perform claims casework for the County's various self-insurance programs including general liability, medical malpractice and workers' compensation claims. Incumbents, within delegated settlement authority, bring such cases to resolution by recommending the acceptance or denial of claims and to adjust cases involving the County's various self-insured programs from the initial report to final resolution.


The level at which the position will be filled is at the Department's discretion and is based on candidate qualifications.Required: A California Self-Insured Certificate issued by the State of California Office of Self-Insurance Plans (OSIP)  is required at the time of application. 
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EXAMPLES OF ESSENTIAL DUTIES


Claims Adjuster I


• Workers' Compensation Claims: Reviews, investigates and processes reports and claims concerning on-the-job injuries or job-related illness of County employees for claims filed against the County and determines if the illness or injury is compensable; arranges disability evaluation appointment and maintains medical control; responds to inquiries from excess insurance carriers, doctors, and legal professionals.

• Prepares cases for legal defense; assists in the preparation of appeals cases before the Workers' Compensation Appeals Board; secures documentary evidence of births, deaths, marriages and divorces in fatality cases.

• Evaluates advisory and informal ratings as a basis for claims settlement; rates permanent disabilities pursuant to California Rating Schedule; approves payment for medical services, temporary disability and permanent disability awards subject to delegated authority as determined by the Risk Management Division Manager.

• Prepares subrogation recovery cases; analyzes investigative and police reports; arranges special investigations and medical examinations.

• Develops, maintains, and analyzes statistical data on claims expenditure trends and provides appropriate report and recommendations; stays abreast of current Workers' Compensation and civil claims litigation.

• Senior Workers' Compensation Claims: Assigns and reviews the work of Adjusters and Technicians; trains and provides technical assistance to new and journey-level Adjustors.

• Examines and adjusts third party claims, via contract, for County Departments with special programs.

• Coordinates the County's defense appeal for safety disability retirement denials and makes presentation before the retirement appeals board.

• Assists the Workers' Compensation Officer with the implementation of special programs such as in-house litigation; determines which claims for adjudication will be litigated by in-house staff.

• Assists in the supervision and maintenance of statistical and budget records and participates in studies of industrial accident matters.

• Gathers and reviews data, reports and other claim documentation; requests clarifying or additional information; reviews status and performs necessary follow up.

• Conducts investigations to determine circumstances involved in claims against the County; including interviewing witnesses and inspecting the scene of accidents, injuries or property damage; prepares investigative report of findings.

• Conducts interviews with parties responsible for damage to County property and injuries to County employees to ensure collection of payments; contacts public and private organizations/agencies to obtain collections information; recommends actions necessary to enforce collections including court actions or liens.

• Represents the County in small claims actions.

• Prepare reports of costs and status on active and closed claims.

• May authorize subrogation, court actions or liens when collections can not be obtained by other means; reviews and makes recommendations for suspension, modification, garnishment or other legal actions; corresponds with attorneys, insurance carriers and others; interprets legal procedures involved in the collection or subrogation accounts.

• Consults with attorneys to prepare cases for litigation.

• Serves as custodian of records; provides subpoenaed records and attests to their validity.

• May assign and review the work of others and provide training to new employees.

• Assists the program supervisor to develop and maintain claims records and computer record keeping systems; assures accuracy conformance to policies and procedures and accessibility of claims records.

• Assists attorneys in the preparation of complex case for litigation ensuring the availability and accuracy of all necessary documentation.

• Assigns and reviews the work of Adjusters and Technicians; trains and provides technical assistance to new and journey-level Adjustors.

Claims Adjuster II
Workers' Compensation Claims:
• Reviews, investigates and processes reports and claims concerning on-the-job injuries or job-related illness of County employees for claims filed against the County and determines if the illness or injury is compensable; arranges disability evaluation appointment and maintains medical control; responds to inquiries from excess insurance carriers, doctors, and legal professionals.
• Prepares cases for legal defense; assists in the preparation of appeals cases before the Workers' Compensation Appeals Board; secures documentary evidence of births, deaths, marriages and divorces in fatality cases.
• Evaluates advisory and informal ratings as a basis for claims settlement; rates permanent disabilities pursuant to California Rating Schedule; approves payment for medical services, temporary disability and permanent disability awards subject to delegated authority as determined by the Risk Management Division Manager.
• Prepares subrogation recovery cases; analyzes investigative and police reports; arranges special investigations and medical examinations.
• Develops, maintains, and analyzes statistical data on claims expenditure trends and provides appropriate report and recommendations; stays abreast of current Workers' Compensation and civil claims litigation.
Senior Workers' Compensation Claims:
• Assigns and reviews the work of Adjusters and Technicians; trains and provides technical assistance to new and journey-level Adjustors.• Examines and adjusts third party claims, via contract, for County Departments with special programs.• Coordinates the County's defense appeal for safety disability retirement denials and makes presentation before the retirement appeals board.• Assists the Workers' Compensation Officer with the implementation of special programs such as in-house litigation; determines which claims for adjudication will be litigated by in-house staff.• Assists in the supervision and maintenance of statistical and budget records and participates in studies of industrial accident matters.

MINIMUM QUALIFICATIONS


Claims Adjuster I
$34.98 - $49.62 Hourly
$72,759.65 - $103,205.86 Annually
 

Certificate Required

:

A California Self-Insured Certificate issued by the State of California Office of Self-Insurance Plans (OSIP)  is required at the time of application.
Experience: Considerable journey-level experience reviewing and processing Workers' Compensation, on-the-job injuries, job-related illnesses, physical disability, personal injury, medical malpractice or property damage liability claims including investigating, adjusting and settling a wide variety of claims. For employees assigned to the Workers' Compensation Unit, must have achieved the level of Designated Claims Adjuster (as defined by California Code of Regulations, Title 10, Chapter 5, Subchapter 3) by possessing one of the following. 1) Working 5 out of the last 8 years as a California Worker's Comp Claims Adjuster, 2) Has worked continuously in California adjusting claims since passing the Self-Insurance Test, or 3) Has passed the Self-Insurance test in the last 2 years.
 
Claims Adjuster II
$41.17 - $58.44 Hourly
$85,630.69 - $121,545.63 Annually
 

Certificate Required

:

A California Self-Insured Certificate issued by the State of California Office of Self-Insurance Plans (OSIP)  is required at the time of application.
Experience: Extensive journey-level experience reviewing and processing Workers' Compensation, on-the-job injuries, job-related illnesses, physical disability, personal injury, medical malpractice or property damage liability claims including investigating, identification and investigation of fraud cases, adjusting and settling a wide variety of claims. For employees assigned to the Workers' Compensation Unit, candidates must have achieved the level of Experienced Claims Adjuster (as defined by California Code of Regulations, Title 10, Chapter 5, Subchapter 3) defined as possessing one of the following: 1) Working 5 out of the last 8 years as a California Worker's Comp Claims Adjuster, 2) Has worked continuously in California adjusting claims since passing the Self-Insurance Test, or 3) Has passed the Self-Insurance test in the last 2 years. 

All Levels

Knowledge of: State of California Labor Code, Workers' Compensation Law and rules and regulations (Title 8); Applicable case law of leading decisions of the Workers' Compensation Appeals Board, Court of Appeals, and Supreme Court regarding workers' compensation cases; Medical terminology, anatomy and technical terminology used in medical and legal fields regarding industrial cases; Jurisdiction, functions and procedures of the Workers' Compensation Appeals Board; Vocational rehabilitation and procedures as it applies to Workers' Compensation; Reserving practices and procedures; in-house litigation procedures; WCAB procedures; and hearing processes.

Knowledge of: Practices, techniques and methodologies used in claims investigation, evaluation, adjustment and settlement; Basic rules, regulations, and laws regarding personal and property liability; Principles and techniques of analytical data collection; Principles of insurance reserving, risk and experience analysis and statistical record keeping; Basic mathematics including valuation and depreciation; Computer applications programs and equipment to effectively gather, maintain and report claims data.

Ability to: Communicate, orally and in writing, effectively with a wide variety of people contacted in the course of work; Interpret and apply complex rules, regulations and memoranda of understanding; Establish and maintain cooperative and effective relationships with a broad range of professional staff including attorneys and related legal staff, department heads and managers and all those contacted during the course of performing professional responsibilities; Collect, interpret and evaluate data, develop alternatives and make appropriate recommendations within established guidelines; analyze problems and take effective courses of action; Interpret laws, regulations, and insurance policies; Make accurate mathematical computations; Prepare and present effective written and oral reports and presentations; Maintain professional credibility.

GENERAL APPLICATION INFORMATION:

Please read and follow any special application instructions on this posting. Click the 'Apply' link located on this page to submit your application. For instructions on the application process, examinations, Veteran's preference, pre-employment accommodation or other employment questions, please refer to our web site, . A pre-employment physical examination and background check may be required.

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