See Workers’ Compensation Adjudicator 1

In the Department of Labor and Industries; positions at this level provide leadership and are the technical resource responsible for mentoring, coaching or formal training to lower-level Workers’ Compensation Adjudicators.

Positions at this level use in-depth knowledge of the program area to independently carry out assignments in one of the following areas:
• Claims Administration program: adjudicates, negotiates, and resolves workers’ compensation claims that are protested or appealed, or performs external quality assurance reviews of worker’s compensation claims and pension benefits;
• Crime Victims Compensation program: manages, adjudicates, negotiates, and resolves a caseload of injury claims including total permanent disability cases that are catastrophic in nature;
• Fraud Prevention program: monitor and reviews workers’ compensation claim fraud complaints, analyzes claims and other data to detect fraudulent activity;
• Self-Insured program: adjudicates, negotiates and resolves workers’ compensation claims that are protested or appealed.

Responsible for final determinations on contested workers' compensation claims on issues involving coverage, extent of entitlement to benefits, jurisdictional matters and other decisions by lower-level adjudicators which are contested by the worker, beneficiary, employer, care provider or their lay or legal representatives; authorized to engage in and achieve negotiated settlements of disputed issues;

Reviews all claims appealed to the Board of Industrial Insurance appeals by an injured worker, beneficiary, employer, care provider or their lay or legal representatives and authorized to reassume jurisdiction of the claim from the Board for the purpose of addressing new issues raised by the appealing party or to engage in further negotiations toward settlement of the appeal;

Assists staff from the Office of Attorney General in defense of claims appealed to the Board of Industrial Insurance Appeals, Superior Court or a higher court;

Reviews decisions of the Board of Industrial Insurance Appeals and judgments from Superior Courts, the Court of Appeals and the Washington State Supreme Court and refers for action by the appropriate work section within the department;

Mentors claims managers to use independent judgment to manage claims using RCWs, WACs, policies, case law and department resource; ensures compliance with established work standards and provide documented feedback regarding employees' performance to supervisor, coach, and employee;

Checks the work of Apprentices and trainees based on Critical Breakout Lists and provide feedback to supervisor, coach, and employee;

Performs internal and external quality assurance function including auditing and measuring the performance of peers and lower-level adjudicators, providing written evaluation and reports of any finding; develop strategies to address issues;

Trains all levels of Workers' Compensation Adjudicators in a formal training program; plans, organizes and develops appropriate course material and presentations;

Participates in one-on-one on the job training sessions to apply principles learned in class;

Coordinates caseload assignments for adjudicative staff during formal training periods or skill enhancement plans;

Perform the duties of the lower level in the series;

Performs 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, crime victims compensation rules and statues, 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, drugs, prosthetic devices and their indications; tort law pertaining to third party actions.

Ability to: review determinations and counterclaims from disabled workers, physicians, employers, third parties and determinations made by others 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, physicians, 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.

One year of experience as a Workers’ Compensation Adjudicator 3.

A Bachelor's degree

AND

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

OR

Equivalent education/experience.

June 26, 1964, Retitled from Disability Claims Adjudicator 5 and spec. amended.
Revised definition, minimum qualifications and general revision October 12, 1979.
Revised definition August 15, 1986.
Revised definition and minimum qualifications September 11, 1987.
Revised definition and minimum qualifications, title change (formerly Disability Claims Adjudicator 3) May 1, 1990.
New class code: (formerly 47900) effective July 1, 2007.
Base range salary adjustment, revised definition, typical work, knowledge and abilities, and desirable qualifications, and new class series concept, distinguishing characteristics, adopted June 22, 2023, effective July 1, 2023.