Workers Compensation Claims Adjuster III

About AvonRisk and the Role

AvonRisk is a leading specialty risk management firm for self-insured organizations, operating across 32 states with nearly 700 professionals. The organization includes brands such as Intercare, InterMed, George Hills, and AS&G Claims Administration, focusing on reasonable caseloads, strong training, team collaboration, and expert support. AvonRisk invests in tools and workflows to streamline processes and foster career progression and leadership development. Employees are supported to exercise sound judgment, curiosity, and accountability.

Job Summary

This position reports to the unit Claims Supervisor and may provide technical backup when the supervisor is absent. The role involves managing a portfolio of claims, including complex cases with unusual issues, adhering to relevant laws and company policies, and achieving assigned performance goals.

Key Responsibilities

• Contact the claimant, employer, and treating physician within 24 hours of receiving a new claim to gather necessary information about the incident, disability status, and treatment.
• Maintain thorough, accurate documentation of case facts pertinent to compensability, disability benefits, vendor use, and case closure progress.
• Keep an updated action plan for all indemnity claims outlining steps toward resolution.
• Collaborate with medical case managers to facilitate early return to work, minimizing extended disability payments and rehabilitation costs.
• Refer suspected fraud cases to the Special Investigations Unit (SIU).
• Pursue subrogation claims against third parties, seek contributions in multi-defendant cases, and manage apportionment for pre-existing disabilities.
• Ensure compliance with applicable laws, service contracts, and company guidelines in all claim handling activities.
• Review and approve vocational rehabilitation plans.
• Set, monitor, and adjust monetary reserves within authorized limits as needed.
• Assess medical bills for appropriateness prior to payment processing and attachment to claims.
• Maintain professionalism and courtesy when interacting with all parties, reflecting the company’s image positively.
• Return phone calls within 24 hours and respond to written inquiries within one week.
• Possess detailed knowledge of California Labor Code as it applies to workers compensation claims management.
• Manage and oversee litigation processes related to claims.
• Perform additional duties as directed by supervisors or managers.

Required Competencies

• Problem Solving: Capable of timely issue resolution by analyzing information and devising alternatives using rational judgment.
• Customer Service: Handles challenging or emotional interactions effectively, promptly addressing service requests and fulfilling commitments.
• Interpersonal Skills: Maintains confidentiality, manages conflicts constructively, listens attentively, controls emotions, and remains receptive to new ideas.
• Teamwork: Actively contributes to collective efforts for success.

Qualifications and Experience

The candidate should hold a bachelor's degree and have at least seven years of related experience or an equivalent mix of education and experience. A minimum of five years managing indemnity claims, especially complex cases involving subrogation, rehabilitation, medical management, or legal matters, is required. Possession of a Stakeholder Insurance Professional (SIP) certificate is necessary.

Compensation and Benefits

The estimated salary range is $95,000 to $98,000 annually, with actual pay based on experience, skills, qualifications, and location.

• Comprehensive medical, dental, and vision insurance coverage.
• Company contributions to Health Savings and Flexible Spending Accounts.
• Life and disability insurance fully paid by the employer.
• 401(k) plan with company matching contributions.
• Paid time off and company-recognized holidays.
• Learning and development programs supporting career progression.
• Employee assistance resources promoting wellness and work-life balance.

Equal Employment Opportunity

The employer is an equal opportunity organization, considering all applicants regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability. Additionally, in compliance with the Los Angeles and San Francisco Fair Chance Ordinance, applicants with arrest or conviction records are considered.