Claims Adjuster resume example

Adjuster handling workers compensation claims from the Uninsured Employers Benefits Trust Fund (UEBTF) when illegally uninsured employers fail to pay workers' compensation benefits awarded to their injured employees by the Workers' Compensation Appeals Board. Complete a thorough investigation on all disability and selected non-disability claims to determine if a claim is compensable or not. Identify work capabilities to reduce Total Temporary Disability and facilitate early return to work and pro-actively pursue modified duties and release to full duties. Ensure injured workers receives appropriate medical treatment until discharged from care or maximum medical improvement and confirm all treatment is for conditions that are medically caused by the work injury to achieve cost effective quality claim settlements on claims. Control/contain medical costs, including drug regimens and monitor treatment plans to achieve full and final resolution on each assigned claim. Reduce claim cycle time and resolve claims at earliest opportunity by working with state agency personnel in getting their injured workers back to gainful employment, and ensuring timely and accurate liability decisions.

Leads audits of workers' compensation insurers, self-insured employers, and third-party administrators to assure compliance with the law and regulations of the Administrative Director; acts as lead person for compliance officers, reviewing audit worksheets and proposed assessments and providing the WCCO with on-the-job training and advice on audit guidelines and procedures; identifies violations, determines administrative penalties, explains audit findings, prepares and issues preliminary reports and notices of penalty assessments. Conducting monthly workshops to Claims Administrators and the public. Lead Utilization Review investigations in accordance with LC 4610, 9792.6 - 9792.12.

Conducts post-audit conferences following the three phases of the audits and UR investigations, makes decisions regarding disputed penalties and mitigation involving violations; meet with audit subjects and legal representatives to explain the bases for decisions in disputed penalties, issues final audit reports, Prepares accurate summaries of disputed audit issues and penalties, including recommended decisions and the reasons for the decisions, for submission for approval to the Administrative Director on appealed audit penalties; testifies at hearings and judicial proceedings. Provides complaint analysis as needed.

Reviews complex files, performs complex earning calculations, review and responds to complex rebuttals, perform detailed analysis of liability determinations, perform permanent disability ratings. Assists with the annual calculation of the audit score for PAR and FCA and maintaining the audit glossary for all audit staff.

Represents the Division in meetings and conferences and makes presentations. Interact with injured workers and vendors in relation to complaints and indemnity audit compliance.

Conducts special projects and performs other duties as required. Assisting with data collection on the Annual Audit Report.