Claims Adjuster

AvonRisk; Long Beach (CA); On-site; USD 99,000 - 121,000; Full time

Job summary

AvonRisk is seeking a seasoned Workers' Compensation Claims Adjuster in California to manage all aspects of complex claims, determine compensability, verify coverage, and administer benefits. The role requires engaging with claimants, employers, medical professionals, and counsel to pursue timely settlements and return-to-work outcomes.

Responsibilities include reviewing claims, setting reserves, negotiating resolutions, and coordinating with medical and legal partners while maintaining accurate

Qualifications

• 10 years of experience adjusting workers' compensation claims in California.
• SIP Certification required.
• Bilingual Spanish/English required.
• Must be current with CEU's.
• Proficiency in Microsoft Office suite.
• Knowledge of relevant workers' compensation laws.
• Strong grasp of medical terminology.
• Excellent oral and written communication abilities.
• Attention to detail and good organization skills.
• Ability to negotiate issues and settlements.
• Strong focus on customer service which includes timely response to requests/inquiries.
• Ability to adapt to changing technologies and learn functionality of new equipment and systems.
• Ability to establish and maintain effective working relationships with others.

Responsibilities

• Receives newly reported claims.
• Maintains and updates claim notes throughout lifespan of claim.
• Records claim information in electronic database.
• Interviews claimants, insureds, medical professionals and witnesses to determine claim validity.
• Communicates claim compensability decisions to claimant, employer and medical provider.
• Sets appropriate reserves based on nature/extent of injury.
• Calculates lost time wages, makes disability payments directly to claimants and diaries future payments as appropriate.
• Orders independent medical examinations as necessary and prepares documentation for physician review.
• Maintains regular correspondence with claimants, insureds, and nurse case manager for updates and issues.
• Reviews and processes medical bills through third-party vendor for discount opportunities.
• Collaborates with claimants and insureds to pursue early return-to-work.
• Works with legal counsel to defend insured’s interests on litigated claims.
• Attends settlement conferences, mediations, and hearings.
• Reviews and approves defense attorney bills within authority.
• Interacts with underwriting and Risk Management for renewal rates and trends.
• Responds to state requests for health cost disputes and penalties.
• Identifies subrogation potential and pursues recovery.
• Leads claim reviews with clients when requested.

Skills

Workers' comp claims experience

Bilingual: Spanish/English

Microsoft Office proficiency

Communication skills

Negotiation skills

Education

SIP Certification

Tools

Microsoft Office Suite

Job description

Description

Job Summary

The Workers Compensation Claims Adjuster is responsible for managing all aspects of a workers compensation claim which includes determining compensability, verifying coverage, administering disability and medical benefits, skillfully negotiating claim resolutions, troubleshooting and assisting injured employees, employers and medical/legal professionals with any service needs throughout the lifespan of a claim.

Essential Functions

• Receives newly reported claims
• Maintains and updates claim notes throughout lifespan of claim
• Records claim information in electronic database
• Interviews claimants, insureds, medical professionals and witnesses to determine claim validity
• Communicates claim compensability decisions to claimant, employer and medical provider
• Sets appropriate reserves based on nature/extent of injury
• Calculates lost time wages, makes disability payments directly to claimants and diaries future payments as appropriate
• Orders independent medical examination as necessary and prepares all relevant documentation for physician review
• Maintains regular correspondence with claimants, insureds, and nurse case manager to include claim updates, medical appointments, or issues with disability payments
• Reviews and processes medical bills through third-party vendor for additional discount opportunities
• Aggressively collaborates with claimants and insureds to ensure early return-to-work is pursued
• Works in partnership with legal counsel to warrant that insured’s interests are protected on litigated claims which includes providing all relevant claim documentation needed for defense counsel to successfully defend claim and evaluate ultimate claim exposure.
• Attends settlement conferences, mediations, and hearings on behalf of the insurance company/insured.
• Reviews and approves defense attorney bills within authority
• Works with underwriting to help provide relevant information on losses for renewal rates as well as Risk Management to identify trends and may interact with agents for insureds on losses.
• Responds to State requests for health cost disputes, applications for hearings and penalty assessment letters.
• Identifies subrogation potential and pursues recovery
• Leads claim reviews with clients as requested
• Other duties as assigned

Requirements

• 10 years of experience adjusting Workers Compensation Claims in California required
• SIP Certification required
• Bilingual (Spanish/English) required
• Must be current with CEU's
• Proficiency in entire Microsoft Office suite
• Knowledge of relevant workers compensation laws
• Strong grasp of medical terminology
• Familiarity with medical cases and how treatment typically progresses
• Excellent oral and written communication abilities
• Attention to detail and good organization skills
• Ability to negotiate issues and settlements
• Strong focus on customer service which includes timely response to requests/inquiries
• Ability to adapt to changing technologies and learn functionality of new equipment and systems
• Ability to establish and maintain effective working relationships with others

The annual salary for this role is $110,000.