Claims Adjuster (Special Investigations Unit)

About the role

Basic Function Responsible for investigating claims with suspected fraudulent elements and administering assigned claims involving property damage, third party injury claims, and worker’s compensation claims. Performs duties in a safe, efficient manner and in compliance with applicable rules and safety procedures.

Responsibilities

• Investigates and administers assigned Liability and Worker’s Compensation claims with potentially fraudulent elements such as staged accidents, unsubstantiated claims, suspicious property damages, exaggerated injuries, and manufactured records or invoices.
• Analyze, investigate, establish liability, evaluate damages, and resolve potential fraudulent claims across various lines of coverage.
• Take recorded statements from parties involved and explain the Texas Tort Claims Act Law as needed.
• Conducts thorough research on individuals using public records, social media, surveillance, canvassing, law enforcement records, court records, and internal databases.
• Coordinates with local law enforcement, insurance companies, and legal counsel for potential litigation or filing of criminal charges.
• Sets appropriate diary date schedule according to approved intervals of file reviews.
• Requests indexing of all injured parties through Insurance Service Office and Centers for Medicare and Medicaid Services.
• Requests damage appraisals, police reports, medical bills, medical reports, and wage information.
• Sets appropriate financial reserves, either factor or case reserves, and maintains adequate funding.
• Acts as the Claims Department liaison with the District Attorney’s Office on criminal mischief cases.
• Maintain contact with all parties regarding claims (i.e., claimants, appraisers, medical providers, and vendors).
• Provides any additional information requested by supervisor relating to claims.
• Pursues subrogation when applicable.
• Provides excellent customer service to METRO internal and external customers.
• Applies Safety Management System (SMS) methods and principles in daily routine and supports all aspects of the agency’s Public Transportation Agency Safety Plan (PTASP).
• Promotes safety awareness and follows safety procedures to reduce or eliminate accidents.
• Performs other job-related duties as assigned.

Qualifications

• Education Requirement: High school diploma or GED is required. Associate’s degree in Risk Management or Criminal Justice is preferred.
• Years & Experience Required: Minimum five (5) years’ experience in liability and Workers’ Compensation claims investigations and administration.

Skills

• Must have functional knowledge of the Texas Tort Claims Act.
• Must possess a Texas All Lines adjusters’ license.
• Excellent analytical skills in researching and reviewing negligence laws, traffic code, accident reports, statements or interrogatories, medical bills, indexes, and medical narratives.
• Ability to evaluate evidence to substantiate or refute fraud allegations.
• Good communications (written/verbal) skills and the ability to negotiate cost effective settlements.
• Must have basic understanding of insurance and medical terminology.
• Must have basic understanding of compliance with state/federal laws and fair claim handling.

Pay

Pay Range: $70,700 - $92,800