Claims Adjuster
Job description
Performs advanced specialized technical work in the investigation and adjustment of public liability and/or Workers' Compensation claims.
Works under general supervision, independently developing work methods and sequences.
Requires two (2) years equivalent of higher level education in workers' compensation and/or general liability claims adjusting and insurance/risk management.
(One year of relevant experience may be substituted for each year of required education.)
Requires four (4) years in adjusting workers' compensation and/or bodily injury/property damage liability claims or closely related experience.
Special Certifications and Licenses
Must possess and maintain a valid Florida Class E Driver's License for duration of appointment.
Preferences
Doctorate Degree in related field
Associates in Claims Designation (AIC)
Associates in Risk Management Designation (ARM)
Chartered Property Casualty Underwriter Designation (CPCU)
Certified Claims Professional Designation (CCP)
Certified Insurance Counselor (CIC)
2+ years of experience using Clearsight Enterprise claims software.
2+ years of knowledge in reviewing and interpreting insurance contracts
2+ years of knowledge in using Claims Management System
3+ years of experience handling litigated claims and litigation management.
2+ years of experience handling claims against Governmental entities/public sector/Florida Statute 768.28
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.
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 Attorney’s 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 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.
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.
Physical Demands
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 (Work Environment)Unavoidable hazards refer to the job conditions that may lead to injury or health hazards even though precautions have been taken.
None.
County Core Competencies
- 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.
Emergency Management Responsibilities
County-wide Employee Responsibilities
All Broward County employees must establish and maintain effective working relationships with the general public, co-workers, elected and appointed officials and members of diverse cultural and linguistic backgrounds, regardless of race, color, religion, sex, national origin, age, disability, marital status, political affiliation, familial status, sexual orientation, pregnancy, or gender identity and expression.
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