See Workers’ Compensation Adjudicator 1

In the Department of Labor and Industries, this is the senior technical specialist level of the series. Positions at this level of the series are assigned to one of the five defined separate program areas:

• Claims Administration Program: Determines eligibility of workers' compensation claims for permanent total disability and/or death benefits and performs internal and external quality assurance audits of workers’ compensation claims.
• Crime Victims Compensation Program: Determines eligibility of workers’ compensation claims for permanent total disability and/or death benefits.
• Self-Insurance/Pension Program: Determines eligibility of worker’s compensation claims for permanent total disability and/or death benefits or directs activities of the Self-Insurance Claims Penalty Program or formal Training Program.
• Fraud Program: Reviews laws and issues decisions regarding the most complex and egregious fraud cases committed against the department including the amount of fraud overpayments and penalties to be assessed.
• Insurance Services Administration: Employing expert claims knowledge, act and make decisions on behalf of the Assistant Director to oversee the Over 7 reopening request and Overpayment Waiver process including research, file review, and recommending director approval or denial of proposed actions in his or her sole discretion (per statute).

Responsible for adjudication of all phases of claims for fatal injuries, permanent total disability and pension claims by surviving spouses, children and dependents, including determination of diminution of disability; determines employer's eligibility for a reduction in financial charges assessed through entitlement to Second Injury Fund or Catastrophe Fund relief; issues formal orders concerning entitlement to benefits and employer assessments;

Supervises staff assign to the Appeal Review Section and serves as lead consultant to that office; prepares status reports and maintains records on claims which have been appealed to the Board of Industrial Insurance Appeals or higher courts;

In the Self-Insurance Section, is responsible for supervision of adjudication and clerical staff and acts as Claims Manager and assistant to the Program Manager for Self-Insurance.

Acts as Chief Adjudicator and assistant to Supervisor of the Crime Victims Compensation Program; assists the Supervisor in compiling and disseminating statistical, budgetary and other information regarding the section to the legislature and the public; serves as final review of the department on protests or appeals on any determinations made in connection with claims for benefits under the Crime Victims Compensation Program;

Confers with Assistant Attorney General staff on cases in litigation and may be called to testify at the Board of Industrial Insurance Appeals;

Drafts replies for agency in response to inquiries from elected officials;

Conducts audits of State Fund and Self-Insured claims and benefits payment functions within Claims Administration, Legal Services, Regional Offices, and Pension Benefit payments; provides comprehensive written reports;

Reviews and recommends revisions on the design and development of policies and procedures across programs within the Insurance Services Division: Fraud Prevention and Compliance, Employer Services, Self-Insurance, Office of the Medical Director, Health Services Analysis, Return to Work, Stay at Work, Legal Services, Retrospective Rating, and Administrative Services to mitigate systemic problems and achieve optimum effectiveness;

Analyzes legislation affecting workers’ compensation program; determine fiscal impacts; collaboratively develop and implement strategies to meet business and training needs due to new legislation;

May supervise lower-level staff;

Perform the duties of the lower level in the series;

Perform other related work as required.

Knowledge of: Workers' Compensation and Medical Aid Acts and other statutes, court decisions, Attorney General Opinions, Board of Industrial Appeals rulings, and departmental regulations applying to industrial accidents and occupational diseases, past and present, or disability insurance provisions of the Old Age and Survivors Insurance Act; medical terminology, human anatomy and physiology, psychiatric terms, drugs, prosthetic devices and their indications; tort law pertaining to third party actions.

Ability to: Exercise mature judgment in adjudicating disability claims and counterclaims from disabled workers, physicians, employers, third parties and other persons; personally make lawful and equitable determinations regarding eligibility for benefits under the law; write clear, concise, accurate and informative correspondence and reports; establish and maintain effective customer relations and working relationships with workers, physician, employers, legal representatives, co-workers and the general public; compare past records, past and present law, rulings of the Board of Industrial Insurance Appeals and higher courts, and other information to arrive at lawful and equitable decisions regarding benefit entitlements.

There may be instances where individual positions must have additional licenses or certification. It is the employer’s responsibility to ensure the appropriate licenses/certifications are obtained for each position.

Successful completion of the Department of Labor and Industries Workers’ Compensation Adjudicator 2 Apprenticeship program.

AND

One year of experience as a Workers’ Compensation Adjudicator 4.

Bachelor’s degree

AND

Four years of experience in adjudicating workers’ or crime victims’ compensation insurance claims or adjudication of time loss payments.

Equivalent education/experience.

Revised Spec. amended and title change (formerly Disability Claims Adjudicator VI) June 26, 1964.
Revised definition, minimum qualifications, and general revision October 12, 1979.
Revised definition May 11, 1984.
Revised definition September 11, 1987.
Revised Revises definition and minimum qualifications, title change (formerly Disability Claims Adjudicator 4) May 1, 1990.
Revised definition and minimum qualifications: May 12, 2000.
New class code: (formerly 47910) effective July 1, 2007.
Base range salary adjustment, revised definition, typical work, knowledge and abilities, and desired qualifications, and new class series concept, adopted June 22, 2023, effective July 1, 2023.