Claims Adjuster II/Senior Claims Adjuster (Senior Workers' Compensation Claims Adjuster)

County of Riverside • Riverside, CA

1d

About The Position

The County of Riverside Human Resources Department is seeking a Claims Adjuster II/Senior Workers' Compensation Claims Adjuster. This position is responsible for reviewing, analyzing, and evaluating workers’ compensation claims filed against the County. It serves as a functional lead, providing training and guidance to Claims Adjusters and delivering workers’ compensation training to County stakeholders. A California Self-Insured Certificate is required. This role reports to the Workers’ Compensation Officer and manages claims from initial filing through final resolution, including recommending acceptance or denial of claims within delegated settlement authority. The Senior Adjuster also ensures compliance with PRISM (Public Risk Innovation, Solutions, and Management) guidelines, best practices, and state mandates by providing critical audit oversight. The position identifies performance gaps, training needs, and opportunities for process improvement among Technicians, Adjusters, and Supervisors. Successful candidates will have extensive journey-level experience in workers’ compensation claims, including knowledge of alternative dispute resolution (ADR), labor code, PRISM standards, and state audit processes. The level at which the position will be filled is at the Department's discretion and will be based on candidate qualifications. The Human Resources Department strives to effectively serve and partner with our community, departments and employees by leveraging best practices and innovation to foster a thriving county.

Requirements

• A California Self-Insured Certificate is required at the time of application.
• Extensive journey-level experience reviewing and processing complex Workers' Compensation, on-the-job injuries, job-related illnesses, physical disability, personal injury, medical malpractice or property damage liability claims including identification and investigation of fraud cases and investigating, adjusting and settling a wide variety of claims.
• Lead or supervisory experience highly preferred For employees assigned to the Workers' Compensation Unit.
• Candidates must have achieved the level of Experienced Claims Adjuster (as defined by California Code of Regulations, Title 10, Chapter 5, Subchapter 3) defined as possessing one of the following: 1) Working 5 out of the last 8 years as a California Worker's Comp Claims Adjuster, 2) Has worked continuously in California adjusting claims since passing the Self-Insurance Test, or 3) Has passed the Self-Insurance test in the last 2 years.
• Knowledge of State of California Labor Code, Workers' Compensation Law and rules and regulations (Title 8); Applicable case law of leading decisions of the Workers' Compensation Appeals Board, Court of Appeals, and Supreme Court regarding workers' compensation cases; Medical terminology, anatomy and technical terminology used in medical and legal fields regarding industrial cases; Jurisdiction, functions and procedures of the Workers' Compensation Appeals Board; Vocational rehabilitation and procedures as it applies to Workers' Compensation; Reserving practices and procedures; in-house litigation procedures; WCAB procedures; and hearing processes.
• Ability to interpret and apply the provisions of Workers' Compensation laws and determine the liability of the County; Interpret medical and legal briefs and reports; Establish and analyze all relevant data, effect necessary control plans, and bring all claims to equitable conclusion; Evaluate and analyze workers' compensation claims and negotiate/defend to an equitable conclusion; Be a self-starter and work independently.
• A valid California Driver's License is required at the time of appointment or the ability to arrange transportation for field travel.
• The incumbent may be required to use a personal vehicle and provide verification of auto insurance coverage as required by the Job Competencies:
• Work Performance Measures: Effectively analyze and interpret federal and state laws affecting claims.
• Successfully discern and analyze alternatives in technical situations to assist in problem resolution.
• Participate appropriately in meetings as directed by the Workers' Compensation Officer or Liability Claims Program Supervisor.
• Accurately assess and calculate claim settlement costs.
• Successfully analyze information to determine appropriate strategy.
• Succinctly and clearly develop written reports and recommendations as assigned.
• Skillfully utilize computer and other available technology to maintain claims records, supporting documentation and technical/legal information.
• Meet obligations and commitments.
• Effectively investigate a wide variety of claims, data sources, regulations and laws governing claims.
• Take appropriate actions after carefully determining and analyzing all relevant factors.
• Maintain objectivity and credibility.
• Effectively maintain expertise in claims areas impacting the County including legal climate and trends.
• Appropriately utilize creative problem solving, investigative and analysis techniques.
• Persuasively communicate your findings and recommendations to a variety of audiences including attorneys and insurance representatives.
• Successfully prioritize conflicting timelines ensuring that each case or project receives appropriate time and consideration.

Nice To Haves

• Lead or supervisory experience highly preferred For employees assigned to the Workers' Compensation Unit.

Responsibilities

• Reviews, investigates and processes reports and claims concerning on-the-job injuries or job-related illness of County employees for claims filed against the County and determines if the illness or injury is compensable; arranges disability evaluation appointment and maintains medical control; responds to inquiries from excess insurance carriers, doctors, and legal professionals.
• Prepares cases for legal defense; assists in the preparation of appeals cases before the Workers' Compensation Appeals Board; secures documentary evidence of births, deaths, marriages and divorces in fatality cases.
• Evaluates advisory and informal ratings as a basis for claims settlement; rates permanent disabilities pursuant to California Rating Schedule; approves payment for medical services, temporary disability and permanent disability awards subject to delegated authority as determined by the Risk Management Division Manager.
• Prepares subrogation recovery cases; analyzes investigative and police reports; arranges special investigations and medical examinations.
• Develops, maintains, and analyzes statistical data on claims expenditure trends and provides appropriate report and recommendations; stays abreast of current Workers' Compensation and civil claims litigation.
• Assigns and reviews the work of Adjusters and Technicians; trains and provides technical assistance to new and journey-level Adjustors.
• Examines and adjusts third party claims, via contract, for County Departments with special programs.
• Coordinates the County's defense appeal for safety disability retirement denials and makes presentation before the retirement appeals board.
• Assists the Workers' Compensation Officer with the implementation of special programs such as in-house litigation; determines which claims for adjudication will be litigated by in-house staff.
• Assists in the supervision and maintenance of statistical and budget records and participates in studies of industrial accident matters.
• Gathers and reviews data, reports and other claim documentation; requests clarifying or additional information; reviews status and performs necessary follow up.
• Conducts investigations to determine circumstances involved in claims against the County; including interviewing witnesses and inspecting the scene of accidents, injuries or property damage; prepares investigative report of findings.
• Conducts interviews with parties responsible for damage to County property and injuries to County employees to ensure collection of payments; contacts public and private organizations/agencies to obtain collections information; recommends actions necessary to enforce collections including court actions or liens.
• Represents the County in small claims actions.
• Prepare reports of costs and status on active and closed claims.
• May authorize subrogation, court actions or liens when collections can not be obtained by other means; reviews and makes recommendations for suspension, modification, garnishment or other legal actions; corresponds with attorneys, insurance carriers and others; interprets legal procedures involved in the collection or subrogation accounts.
• Consults with attorneys to prepare cases for litigation.
• Serves as custodian of records; provides subpoenaed records and attests to their validity.
• May prepare and present training program educating staff about the Liability Claims Program.
• May assign and review the work of others and provide training to new employees.
• Assists the program supervisor to develop and maintain claims records and computer record keeping systems; assures accuracy conformance to policies and procedures and accessibility of claims records.
• Assists attorneys in the preparation of complex case for litigation ensuring the availability and accuracy of all necessary documentation.
• Assigns and reviews the work of Adjusters and Technicians; trains and provides technical assistance to new and journey-level Adjustors.

Benefits

• The County of Riverside is committed to providing reasonable accommodation to applicants as required by the Americans with Disabilities Act (ADA) and Fair Employment and Housing Act (FEHA).
• The County has a Veterans Preference Policy applicable to new hires.
• The County of Riverside does not participate in visa sponsorship programs, including H1-B visas, and will not provide sponsorship for any employment-based visas.
• The County of Riverside is an Equal Opportunity Employer.
• All employment offers are contingent upon successful completion of pre-employment requirements including a criminal background investigation, which involves fingerprinting.
• A pre-employment physical examination and background check may be required.
• As an Approved Local Merit System, all County of Riverside employees, except those serving "At Will," are subject to the probationary period provisions as specified in the applicable Memorandum of Understanding, County Resolution, or Salary Ordinance.
• Temporary and Per Diem employees serve at the pleasure of the agency/department head.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed