INSURANCE CLAIMS ADJUSTER 21251

03/01/94 B

This class is used by the Department of General Services Division of Risk Management, which administers self-insurance programs for the state and local governments. Positions in this class investigate, evaluate, and determine liability and payment of benefits provided by the Workers' Compensation Plan, and the Property and General Liability Plans.

Complexity of Work: Performs work of moderate difficulty in investigating, evaluating, and determining liability and payment of workers' compensation benefits, property claims, and general liability claims. Typical duties include: receiving claims, determining need for investigation, contacting parties involved, and taking recorded examinations under oath; processing and settling claims; reviewing file documents; determining need for and requesting physician or other medical reports, police reports, experts, estimates, and other reports, determining extent of damage/injury, if injury is related to accident, expected length of liability, and future medical treatment plans. These positions determine if claims are compensable, and, based on the average life of a claim, set aside funds for estimated costs and encumbrances against the state; and determine the need and scope of vocational rehabilitation required. Other duties may include providing data for preparation of legal documents; receiving applications for hearings and preparing position reports for the Office of the Attorney General; giving expert testimony at hearings; authorizing claim payments; recommending hospital bill audits and medical and vocational rehabilitation services; and approving bill payments based on contract agreements.

Supervision Given: Positions in this class typically do not supervise.

Supervision Received: Positions receive direction from an Insurance Program Specialist or Supervisor. Most duties are performed independently.

Scope: The Division of Risk Management administers a statewide self-insurance program for state agencies and political sub-divisions. The work of positions in this class is directly related to the administration of the statewide program.

Impact of Actions: The work performed by positions in this class affects the efficiency, effectiveness, and compliance of the workers compensation claims unit and the property and general liability claims unit. Claims must be settled or defended in accordance with case law and the Code of Virginia. Errors could result in extended litigation and affect the quality and cost containment of the programs.

Personal Contacts: Frequent contact with state agencies, local governments, or claimants to investigate cases, discuss problems, and request information; attorneys inside and outside the state system to discuss cases, discuss potential problems, and discuss resolutions and potential settlements; cost containment vendors, hospitals, physicians, and nurses to discuss cases, problems, claimant status, and prognosis.

Knowledge: Considerable knowledge of the Workers' Compensation Act or the Code of Virginia, constitutional and case law, medical terminology, medical standards of treatment and time frames, claims investigation, negotiation procedures, tort liability, and methods for determining necessary reserves.

Skills: None identified.

Abilities: Demonstrated ability to research and analyze information, and reach logical conclusions; communicate effectively, orally and in writing; and negotiate claims settlements.

QUALIFICATIONS GUIDE*

License or Certification: None.

Education or Training: Graduation from an accredited college or university with major studies in risk management, business administration, or related field.

Level and Type of Experience: Considerable experience in workers' compensation cases or general liability claims, and claims adjustment.

An equivalent combination of training and experience indicating possession of the preceding knowledge and abilities may substitute for this education and experience.

This class was established in May, 1992, as an Insurance Claims Adjuster-Workers' Compensation. The class was revised to include general liability and the title was changed in March, 1994.