Definition

In the Department of Labor and Industries; in Claims Administration, adjudicates, negotiates and resolves workers' compensation claims that are protested or appealed, or performs external quality assurance audits of workers' compensation claims, or trains Workers' Compensation Adjudicators 3 in a formal training program; or in Self-Insurance, adjudicates, negotiates and resolves workers' compensation claims that are protested or appealed, or trains Workers' Compensation Adjudicators 3 in a formal training program.

Typical Work

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 enter into 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 enter into further negotiations toward settlement of the appeal;

Participates as a representative of the department in the process of mediation by a Rules and Resumptions Officer or Industrial Appeals Judge; 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;

Acts on behalf of the director to set attorney fees for services before the department, upon receipt of a request from a worker/beneficiary or their legal representative;

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;

Trains Workers' Compensation Adjudicators 3 in a formal training program; Plans, organizes and develops appropriate course material and presentations;

Assigns incoming caseload to lower level adjudicators;

Performs other related work as required.

Knowledge and Abilities

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, anatomy, drugs, prosthetic devices and their indications; tort law pertaining to third party actions.

Ability to: review determinations and counterclaims from disabled persons, 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.

Legal Requirement(s)

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.

Desirable Qualifications

A Bachelor's degree 

AND

two years of experience in adjudication of time loss payments in a workers' or crime victims' compensation insurance program.

OR

Three years of experience in adjudication of time loss payments in a workers' or crime victims' compensation insurance program or one year as a Disability Claims Adjudicator 2 or equivalent experience.

Experience in claims/insurance adjusting, claims investigation, paramedical occupation, or related field will substitute, year for year for education.

Class Specification History

June 26, 1964Retitled 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