Workers' Compensation Claims Adjuster Series

California State Personnel Board Specification

Series established July 20, 1993

Scope

This series specification describes two classifications which perform specialized workers' compensation claims adjustment duties at the State Compensation Insurance Fund.

Definition of Series

The Workers' Compensation Claims Adjuster series describes professional positions concerned with the adjustment of workers' compensation insurance claims for the State Compensation Insurance Fund. Functional assignments include claims adjustment, catastrophic rehabilitation services, claims training, medical cost containment, claims data processing and operational systems, reinsurance and structured settlements. Work is performed in both field and office settings.

Positions in these classes are not designated as management or supervisory, although incumbents may occasionally act as "leadpersons" performing such functions as training new staff or reviewing the assignments of lower level staff. Such "leadpersons" have duties substantially similar to those of their subordinates and they do not have the authority in the interest of management to hire, transfer, suspend, lay off, recall, promote, discharge, assign, reward, discipline, or responsibly direct other employees, or to adjust their grievances, or effectively recommend such actions.

Typical Tasks

Typical tasks include determine liability, initiate and control delivery of accurate and timely compensation, medical and rehabilitation benefits to qualified injured workers as prescribed by law and within State Fund's guidelines and procedures; determine accurate and adequate estimates on assigned claims; review and analyze case documentation and plan proactive case management strategies; prepare case resumes for policyholders; calculate and negotiate settlements; write correspondence and reports; provide and coordinate all medical and vocational rehabilitation services to the catastrophically injured worker; plan, coordinate and evaluate claims technical training; lead training program project teams;�develop, implement, coordinate and maintain new medical cost containment projects throughout the districts; track regional cost trends on implemented projects; analyze and evaluate analyst service requests for the improvement of data processing systems used in State Fund's claims adjustment functions; implement the findings and recommendations to improve claims data systems; develop and implement training for systems users; develop projects that impact State Fund's claims case management procedures; revise claims manuals and claims forms; identify, evaluate and report reinsurance claims; conduct excess insurance audits and report on the status of excess insurance claims; develop and negotiate structured settlements.

Entry Levels

Entry into this series is from outside State service or by promotion from the classification of Workers' Compensation Insurance Technician, Range B.

Factors Affecting Position Allocation

Variety and complexity of work; independence of action and decision making; sensitivity of client contacts; consequence of error; administrative service responsibilities; and degree of supervision received.

Definition of Levels

Workers' Compensation Claims Adjuster

This includes the entry, first working and journey levels in this series. Positions are permanently allocated to this class when the major portion of tasks performed are not as complex, varied, or responsible as those per formed by a Senior Workers' Compensation Claims Adjuster.

This is the typical professional journey level in the series and claims adjustment, catastrophic rehabilitation, claims training, medical cost containment, claims data processing and operational systems, reinsurance and structured settlement positions may be allocated to this level.

Senior Workers' Compensation Claims Adjuster

This is a super journey level. Relatively few positions will be allocated to this level and then only when the duties of the position are substantially and clearly more complex, varied or responsible than typical claims positions.

Minimum Qualifications

Workers' Compensation Claims Adjuster

Either I

One year of experience in the California state service performing the duties of a Workers' Compensation Insurance Technician, Range B. (Applicants who have completed nine months of the required experience will be admitted to the examination but must complete the required experience before they will be eligible for appointment.)

Or II

Four years of experience performing workers' compensation claims adjusting. (Experience in the California state service applied to this pattern must include at least one year of experience performing workers' compensation claims adjustment duties at a level of responsibility equivalent to that of a Workers' Compensation Insurance Technician, Range B.)

Or III

Education: Equivalent to graduation from an accredited college with a bachelor's degree. Registration as a senior in an accredited college will admit applicants to the examination, but evidence of graduation or its equivalent must be produced before they can be considered eligible for appointment. (Responsible employment in workers' compensation claims adjustment may be substituted on a year for year basis. Experience in the California state service applied to this pattern must include at least one year of experience performing the duties of a class with a level of responsibility equivalent to that of a Workers' Compensation Insurance Technician, Range B.)

Senior Workers' Compensation Claims Adjuster

Either I

One year of experience in the California state service performing the duties of a Workers' Compensation Insurance Supervisor I; a Workers' Compensation Claims Adjuster, Range C; a Workers' Compensation Insurance Representative, Range C; or a Senior Workers' Compensation Payroll Auditor. (Applicants who have completed nine months of the required experience will be admitted to the examination but must complete the required experience before they will be eligible for appointment.)

Or II

Four years of experience in professional workers' compensation claims adjustment. (Experience in the California state service applied toward this pattern must include at least one year of experience performing the duties of a class with a level of responsibility equivalent to that of a Workers' Compensation Insurance Supervisor I; a Workers' Compensation Claims Adjuster, Range C; a Workers' Compensation Insurance Representative, Range�C; or a Senior Workers' Compensation Payroll Auditor.)

Knowledge and Abilities

Workers' Compensation Claims Adjuster

Knowledge of: General arithmetic skills, interpretation of graphs and charts; college level vocabulary; California laws and those of other states relating to workers' compensation and their interpretation; State Fund corporate and operating policies and procedures; general insurance principles and practices; administration of compensation benefits; medical aspects of claims adjustment, rules of evidence and investigation techniques; interpretation of data and reading comprehension.

Ability to: Analyze problems and take effective action; read and write English effectively; communicate effectively; maintain good working relations with those contacted in the course of work; read, interpret, and apply rules, procedures, and policies at a level required for successful job performance; interpret provisions of compensation insurance policies and laws; determine the liability for claims; analyze data.

Senior Workers' Compensation Claims Adjuster

Knowledge of: All of the above.

Ability to: Perform all of the above; and to handle the most varied and complex work assignments; act and make decisions more independently than is required in typical workers' compensation claims positions; and handle the most sensitive client contacts.

Special Personal Characteristics

All Levels:

Willingness and ability to travel extensively; ability to qualify for a fidelity bond; possession of a valid driver license.

Class History