City and County of San Francisco

Under direction, a Worker Compensation Adjuster is responsible for adjusting claims of employees of the City & County of San Francisco and performing other related duties as required for the Workers' Compensation Division of the Department of Human Resources. Essential functions include reviewing and determining liability of workers' compensation claims for injured employees; authorizing medical treatment in consultation with medical experts when necessary; determining and authorizing all indemnity payments; establishing and maintaining adequate reserves on claims within authorized level; interpreting and explaining workers' compensation laws; negotiating and settling claims within authority level on behalf of the City and County of San Francisco; providing direction to claims assistants; preparing various reports and correspondence; conducting effective interviews; and contacting and interacting with client departments. The duties of the job require extensive use of personal computers and telephones.

The Workers' Compensation Adjuster is a professional journey level class and is distinguished from the next higher level of 8165 Workers' Compensation Supervisor I in that the latter acts as a first-line supervisor to a group of adjusters.

According to Civil Service Commission Rule 109, the duties specified below are representative of the range of duties assigned to this job code/class and are not intended to be an inclusive list.

1. Reviews and determines the liability of workers' compensation claims for injured workers within the time limits set by the California Labor Code on Workers' Compensation, by reviewing reports of accidents, analyzing and investigating written and telephone reports of injuries sustained by employees on duty, and authorizing investigations when necessary. Interprets the California Labor Code and applies the workers' compensation laws to determine compensability for each claim and class of benefits, such as temporary disability, permanent disability, death benefits, disability pay, and medical treatment. 
2. Authorizes and monitors medical treatment in consultation with medical experts when needed by requesting medical reports and records, arranging medical evaluations and writing to treating physicians for status reports; monitors physician compliance with California Labor Code; assists in the review of medical bills for fee schedule and contract adherence, as well as appropriateness and payment discrepancies. Interprets and applies medical knowledge and terminology to determine the appropriate course of action. 
3. Establishes and maintains adequate reserves on claims within authorized level to reflect potential value of the claim by examining medical reports and calculating various types of benefits. 
4. Interprets workers' compensation laws to employees, departments, state and federal agencies, doctors, relatives and representatives of employees, as well as members of the public. Addresses, questions, and responds to injured workers, departments, physicians, attorneys, and other vendors regarding issues. 
5. Negotiates and settles claims within authorized level on behalf of the City and County of San Francisco by means of Stipulated Award or Compromise and Release; supplies litigation support by providing files and settlement authority to the City Attorney; recognizes subrogation potential and refers to the City Attorney's Office in a timely manner. 
6. Provides direction to claims assistants in areas such as preparing benefits payments, issuing notices, responding to the injured workers' requests, clarifying pay issues, preparing general correspondence for the medical reports and claims, and other tasks as needed. 
7. Prepares reports, memoranda, file notes, and other correspondence to various individuals/parties such as management, client departments, attorneys, and medical providers. 
8. Conducts effective interviews to collect and analyze information related to industrial injury or illness. 
9. Contacts and interacts with client departments frequently to provide information and address specific requests. 
10. Determines and authorizes all indemnity payments including temporary disability, permanent disability, death benefits, vocational rehabilitation maintenance allowance, life pension, and disability pay. 
11. Performs related duties and responsibilities as assigned.

Knowledge of: California Workers' Compensation laws and medical terminology.

Ability to: research and investigate; analyze medical and investigative reports and apply knowledge of appropriate laws to make determinations; plan, organize, and prioritize tasks in the appropriate order to meet deadlines; speak and write in a clear, understandable, and concise manner to explain complex terms and ideas; establish and maintain effective working relationships; calculate accurate rates and awards; and access, update, and maintain files using various computer systems and software.

These minimum qualifications establish the education, training, experience, special skills and/or license(s) which are required for employment in the classification.  Please note, additional qualifications (i.e., special conditions) may apply to a particular position and will be stated on the exam/job announcement.

Education:
Possession of a baccalaureate degree from an accredited college or university; 

Experience:
One (1) year of verifiable experience adjusting California workers’ compensation claims adjuster and/or a claims assistant. 

License and Certification:
Possession of a Self Insurance Administrator’s Certificate issued by the State of California, Department of Industrial Relations. (Must be obtained within one year of date of hire.) 

Substitution:
Additional experience as a California workers' compensation claims adjuster and/or a claims assistant may substitute for the required degree on a year-for-year-basis. One year of verifiable experience equals thirty (30) semester or forty-five (45) quarter units. 

Completion of college level coursework may substitute for the required degree on a year-for-year basis. Thirty (30 semester or forty-five (45) quarter units. 

A California Workers' Compensation Claims Administration (WCCA) certificate, California Workers Compensation Claims Professional (WCCP) certificate or equivalent from Insurance Educational Association (IEA) or comparable entity may substitute for one (1) year of the required experience or one (1) year of the required education.