Claims Adjuster

Claims Adjuster

Risk Management is actively recruiting for a Claims Adjuster role within the Workers' Compensation division. The Workers Compensation Adjuster is responsible for calculating and processing disability benefits for impairment ratings of 1% or higher, ensuring compliance with benefit issuance to avoid penalties. This role involves setting up medical claims to document and update current work status and treatment. It also entails monitoring and obtaining medical records and work status to ensure timely calculation and payment of indemnity and impairment ratings, completing State EDI mandated reporting within regulated time frames to avoid penalties. The adjuster processes notices of outstanding medical bills to resolve non-payment issues, reviews and corrects reporting by the Center for Medicare/Medicaid Services (CMS) for accuracy, and initiates timely electronic filings to the Division of Workers' Compensation for disabilities exceeding eight days. Additionally, the adjuster conducts recorded interviews with employees and witnesses, contacts injured employees, employers, and medical providers to document claims, and performs field investigations and face-to-face statements to understand the nature of the claim.

This is NOT a remote position.

This announcement will remain active until enough applications have been received and may close at any time.

Minimum Education and Experience Requirements

Requires at least one (1) year of experience in adjusting workers' compensation claims and/or bodily injury and/or property damage liability claims, or closely related experience.

Special Certifications and Licenses

Must hold and maintain a Florida All-Lines Adjuster License (Type 6-20 or 7-20) issued by the State of Florida Division of Insurance, Agents, and Agency Services.

Must hold and maintain a valid Florida Class E Driver's License throughout the duration of the appointment.

Duties and Responsibilities

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 Attorneys 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.

Competencies

• Financial Acumen: Interprets and applies key financial indicators to make better business decisions. Determines and estimates the main direct and indirect costs; makes generally appropriate decisions regarding expenditures. Studies financial and quantitative information; uses data to improve performance.
• Decision Quality: Makes good and timely decisions that keep the organization moving forward. Knows when to act independently and when to escalate issues. Integrates various inputs, decision criteria, and trade-offs to make effective decisions. Typically makes good independent decisions.
• Optimizes Work Processes: Knows the most effective and efficient processes to get things done, with a focus on continuous improvement. Uses metrics and benchmarks to monitor accuracy and quality. Takes steps to make methods productive and efficient. Promptly and effectively addresses process breakdowns.
• Ensures Accountability: Holds self and others accountable to meet commitments. Accepts responsibility for own work, both successes and failures. Handles fair share and does not make excuses for problems. Usually meets commitments to others.
• Drives Results: Consistently achieves results, even under tough circumstances. Holds self to high standards of performance; sets some challenging goals; wants to achieve meaningful results; pursues initiatives/efforts to successful completion and closure. Focuses on key goals, even during setbacks and obstacles.
• Manages Conflict: Handles conflict situations effectively, with a minimum of noise. Seeks out a variety of opinions and options; maintains an open mind; takes steps to ensure conflict remains constructive; avoids polarized or unilateral decisions; seeks agreement on critical issues.
• Communicates Effectively: Develops and delivers multi-mode communications that convey a clear understanding of the unique needs of different audiences. Tailors communication content and style to the needs of others. Pays attention to others' input and perspectives, asks questions, and summarizes to confirm understanding.
• Situational Adaptability: Adapts approach and demeanor in real time to match the shifting demands of different situations. Takes steps to adapt to changing needs, conditions, priorities, or opportunities. Understands the cues that suggest a change in approach is needed; adopts new behaviors accordingly.

Work Environment

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.

Special Information

All Broward County employees strive to demonstrate the County's four core behavioral 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