STATE RISK ADJUSTER 1

AS611 $32,781 - $56,181
Creation Date: 03/17/2003
Change Date: 01/01/2025

FUNCTION OF WORK:
To train in examining insurance claims, applying benefits utilizing established claims processing systems, and developing recommendations regarding the settlement of claims.

LEVEL OF WORK:
Entry

SUPERVISION RECEIVED:
Close from a State Risk Adjuster 5 or State Risk Adjuster of higher level.

SUPERVISION EXERCISED:
None.

JOB DISTINCTIONS:
Differs from the State Risk Adjuster 2 by the assignment of less complex claims and claims that are not in litigation.

CORE COMPETENCIES:
IDENTIFIED BY STATE CIVIL SERVICE, CORE COMPETENCIES ARE THE KNOWLEDGE, SKILLS, ABILITIES AND BEHAVIORS BASED ON THE WORK TASKS OUTLINED IN THE EXAMPLES OF WORK. MORE INFORMATION ON THE SCS COMPETENCY MODEL CAN BE FOUND HERE.

Communicating Effectively	Displaying Expertise	Driving Results
Following Policies and Procedures	Learning Actively	Making Accurate Judgments
Managing Performance	Managing Resources	Managing Stakeholders
Thinking Critically	Using Data

EXAMPLES OF WORK:
EXAMPLES BELOW ARE A BRIEF SAMPLE OF COMMON DUTIES ASSOCIATED WITH THIS JOB TITLE. NOT ALL POSSIBLE TASKS ARE INCLUDED.

OFFICE OF RISK MANAGEMENT:
Participates in in-depth training sessions on use of computerized equipment, reference material, forms, and documents in order to learn the basic skills and techniques to comprehend and apply benefits of insurance according to State Statutes and agency rules, regulations, policies and procedures.

Takes notices of loss and verifies insurance coverage.

Reviews, evaluates, sets reserves, and establishes personal, casualty and property claims which include worker's compensation, automobile physical damage, inter collegiate sport accidents, and general liability.

Requests medical reports and bills from treating physicians and reviews medical reports and statements, and verifies that items billed are related to the claim.

Requests estimates and invoices from claimants and vendors and reviews same to verify that documents received substantiate claim. Requests and reviews police reports.

Maintains contact with injured employees and physicians involved in worker's compensation claims. Contacts treating physicians and/or arranges for independent medical examination of claimant.

Advises claimants of full benefits and limit on claims, methods of attaining same, and direction of responsibility of parties concerned.

Keys alpha and/or numeric information from source documents into a computer terminal; establishing claims. Verifies that batch totals equal totals displayed by terminal; corrects errors in source documents or keyed data; stamps source documents entered.

Reviews complex medical terminology and pertinent claim documents to independently exercise judgment in claim processing.

Performs investigations on claims and acquires pertinent information to substantiate claim.

Recognize and pursue subrogation recovery from third party where applicable to protect interest of State.

PATIENTS' COMPENSATION FUND:
Monitor medical review panel process requesting updates as necessary and making all appropriate computer entries.

Corresponds with primary insurers, defense attorneys, outside claims adjusters to determine validity, exposure and status of claims. Evaluate incoming medical, investigative and discovery information to determine if layer of primary coverage could be exceeded, referring cases of liability and/or value over $100,000 to supervisor.

Must maintain ongoing contact with assigned future medical claimants, their caregivers, vendors and health care providers.

Requests medical reports and bills from treating health care providers. Reviews medical reports and claim information to verify bill submitted relates to medical malpractice claim and all necessary documentation has been received.

Processes requests for payment of related charges after determining if fees are reasonable and customary and disallowing unrelated or unnecessary charges after review of suggested cuts by senior examiner.

Obtains estimates for work done to modify homes and to purchase and modify vehicles for handicapped individuals.

Requests nurse case managers on more complex future medical cases and monitors efforts of nurse

QUALIFICATION REQUIREMENTS:
MINIMUM QUALIFICATIONS:
Three years of experience in insurance claims adjusting, examining, or investigation; accident investigation, legal research, project management, contract management, or construction management; OR

Six years of full-time work experience in any field; OR

A bachelor's degree.

EXPERIENCE SUBSTITUTION:
Every 30 semester hours earned from an accredited college or university will be credited as one year of experience towards the six years of full-time work experience in any field. The maximum substitution allowed is 120 semester hours which substitutes for a maximum of four years of experience in any field.