Contract Claims Adjuster Jobs in Riverside, CA (NOW HIRING)

Under general direction of Workers' Compensation Manager, ensures timely processing of workers' compensation claims and evaluates accident reports to determine accuracy and completeness to include handling all day to day functions of the workers' compensation department.

ESSENTIAL FUNCTIONS:

Evaluates accident reports for completeness of reports to ensure the proper paperwork and information has been reported from the 5 hospitals. If the proper paperwork is not complete, follow up is completed to ensure correct paperwork.

Handles day to day duties of workers' compensation program which include multiple tasks and requirements from Workers' Compensation Manager.

Duties to include Reporting Injuries and referrals to our hospital for treatment.

Evaluates claims and recommends necessary services to include Nurse Case Management, Investigation, Modified Duty, and any other services that may be needed on the file to ensure proper handling.

Ensures TPA has all necessary documents to process and adjust claims for KPC Healthcare. If TPA needs any other information or documentation the follow up is completed by the Work Comp Specialist.

Communicates with TPA on the handling and adjusting of the workers' compensation claims as needed and responds to requests from TPA regarding information needed for adjusting the claims.

Determines what information or additional documentation is needed when requested by the TPA, and obtains the necessary information/documentation.

Determines and recommends what type of Investigation Services are needed on a case. Once approved they make the referral to the TPA, within the guidelines of the approved services. If statements are needed, they determine whose statement needs to be taken and facilitates the times and dates with the TPA and Investigation Company.

Reviews documentation and or medical reports/status to determine whether temporary total disability benefits should be paid, stopped or continued and communicates findings with TPA.

Advises and/or assists departments in conducting investigation of accident reports, including interviewing of witnesses and procurement of relevant documentation.

Reviews accident reports to identify patterns of injury and to determine whether unsafe conditions contributed to the accident; advises departments of trends in injuries and proper safety procedures that may result in reduction of injuries; provides department with information that will aid in reducing accidents and improve safety.

Documents telephone conversations, witness statements, medical reports and accident investigation results.

Attends seminars, conducts research, and maintains liaison with multiple Hospital Departments along with daily communication with the TPA’s handling adjusters.

Assists and preforms reporting of workers’ compensation claims utilizing available computer programs, as needed.

Reviews, evaluates, interprets and applies existing laws pertaining to workers’ compensation, ensuring compliance with legal requirements, company policies, procedures, and union contracts.

Evaluates and assists Workers' Compensation Manager regarding performance of third party claims administrators, legal counsel, medical providers, and other business partners, with an emphasis on team development.

Advises employees regarding workers’ compensation matters when needed and or requested.

Attends TPA quarterly claims reviews with Workers’ Compensation Manager and all other workers' compensation meetings and or discussions.

Evaluates potential modified duty candidates at all 5 hospitals and coordinates with the hospital’s HR Department and employees Department Manager to see if the imposed work restrictions are being accommodated. If accommodated they arrange the signing of the Modified Duty Program document with all parties.

Updates the TD and Modified Duty logs to ensure accurate tracking of these programs.

Determines and Recommends if an injured employee is a candidate for our offsite Modified Duty Program. If they are determined to be a viable candidate, they will notify the injured employee and advise the TPA to make the referral and will monitor the program on a monthly basis.

Reviews and updates return-to-work medical policies/procedures and ensures compliance with KPC Healthcare Inc. LOA Program and works with LOA Specialist when needed on the Interactive Process

Requirements:

Requires knowledge, skills, and mental development equivalent to the completion of four (4) years of college or any equivalent combination of training and experience.

Minimum of 3 years of workers' compensation experience in handling, adjusting, evaluating or maintaining files for an employer, insurance company or TPA.

Effective interpersonal, analytical and negotiation abilities required.

Ability to provide information in a clear, concise manner with an appropriate level of detail.

Demonstrated ability to build and maintain effective relationships.

Requires the drive to continue their education by attending seminars and formal workers’ compensation classes in order to achieve the designations of Workers’ Compensation Claims Administrator (WCCA) and Worker’s Compensation Claims Professional (WCCP).

Benefits:

• Medical, dental and vision coverage is provided for all full time and part time employees*
• Medical is 100% employer paid including dependents*
• Basic Life and AD&D
• 401k plan with company match
• Generous PTO plan*
• Pet Insurance Discount Program*
• Employee Discount Program*

*per diem staff ineligible