Claims Adjuster

Full Job Description

High-Deductible Health Plan – bi-weekly premiums:

Single $10.90 / Family $80.79

Includes a County Funded Health Savings Account of up to $2000 Annually

Consumer Driven Health Plan – bi-weekly premiums:

Single $82.58 / Family $286.79

Florida Retirement System (FRS) – Pension or Investment Plan

457 Deferred Compensation employee match

Eleven (11) paid holidays each year

Vacation (Paid Time Off) = 2 weeks per year

Up to 40 hours of Job Basis Leave for eligible positions

Tuition Reimbursement (Up to 2K annually)

Requirements

The functions listed below are those that represent the majority of the time spent working in this class. Management may assign additional functions related to the type of work of the job as necessary.

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.

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.

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

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.

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.

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

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

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

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 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.

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

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

Conducts recorded interviews with employees and witnesses.

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.

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.

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 Attorney’s office to support the claims process.

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

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 approval 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 claimant's 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.

Attends meetings with other Divisions, Professional Standards/Human Rights Section (PS/HRS), and Human Resources to discuss complex claims.

Performs related work as assigned.

Qualifications

Physical demands refer to the requirements for physical exertion and coordination of limb and body movement.

Performs sedentary work that involves walking or standing some of the time and involves exerting up to 10 pounds of force on a regular and recurring basis or sustained keyboard operations.

Unavoidable hazards refer to the job conditions that may lead to injury or health hazards even though precautions have been taken.

None.

Additional Information

• Financial Acumen

• Decision Quality

• Optimizes Work Processes

• Ensures Accountability

• Drives Results

• Manages Conflict

• Communicates Effectively

• Situational Adaptability

• Collaborates: Building partnerships and working collaboratively with others to meet shared objectives.
• Customer focus: Building strong customer relationships and delivering customer-centric solutions.
• Instills trust: Gaining the confidence and trust of others through honesty, integrity, and authenticity.
• Values differences: Recognizing the value that different perspectives and cultures bring to an organization.