Definition

In the Department of Labor and Industries; in Claims Administration, adjudicates and manages a caseload of compensable workers' compensation claims, trains Workers' Compensation Adjudicators 1 and 2 in the formal training program, adjudicates third party recoveries, or determines social security offsets/ or pension benefit levels; or in Crime Victims, adjudicates and manages a caseload of crime victims claims, or adjudicates third party recoveries; or in Self-Insurance, adjudicates, manages, monitors and regulates self-insured employers' workers' compensation claims for compliance with the Industrial Insurance Laws; or in Risk Management, acts as a consultant on Industrial Insurance claims for the employers participating in group insurance programs.

Distinguishing Characteristics

Positions assigned to this class which are responsible for the management of compensable claims, involve more than 14 days of time loss with level 3 complexity factors or level 3 complexity factors in crime victims.

NOTE: Level 3 complexity factors are determined by the Labor and Industries claims assignment system matrix.

Typical Work

Reviews and adjudicates Industrial Insurance or Crime Victim claims; interprets facts and applies laws in determining claim validity; establishes rate of compensation for allowed Industrial Insurance or Crime Victim benefit payments;

Evaluates and authorizes or denies requests for medical treatment, surgery, diagnostic studies, transfer of physicians and reimbursement of claimant's travel expenses;

Responds to telephone and written inquiries from physicians, employers, claimants and attorneys regarding a claim's status and the department's rules and regulations; composes medical examination and investigation assignments and legal orders;

Reviews decision, claims files and examines medical reports to determine permanent partial disability; authorizes and processes appropriate awards, receives, reviews and authorizes or denies requests for lump sum payments and advances on permanent partial disability awards;

Makes decisions on requests for reopening of claims; reviews and investigates requests for accident fund benefits received after statutory time limitation and recommends appropriate action to the agency Director;

Establishes case reserve by estimating the cost of each claim; resolves disputes between employers, attorneys and the department regarding case reserve amounts;

Determine need for vocational services; approves or denies formal plans on vocational services;

Adjudicates protests to determinations made regarding entitlement to benefits under the Industrial Insurance Laws;

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 occupation diseases, past and present, medical terms, anatomy, psychiatric terms, drugs, prosthetic devices, and their implications; tort law pertaining to third parties.

Ability to: Exercise mature judgment in adjudicating disability claims and counterclaims from disabled persons, physicians, employers, third parties and other persons and 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 claimants, physician, fellow employees, and the general public; compare past records, past and present law, Industrial Insurance Appeals Board rulings and higher costs, and compute valid lump sum payments for past unpaid time loss accurately; abstract pertinent medical psychiatric and other clinical information from hospital and Labor and Industries records.

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

One year of experience in adjudication of time loss payments in a worker's or crime victims' compensation insurance program.

OR

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

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

Class Specification History

Specification amended, change specification number and title change (formerly Disability Claims Adjudicator IV, 4788) Effective June 26, 1964
Revises minimum qualifications Effective December 22, 1970
Revised October 12, 1979 Revises definition, minimum qualifications and general revision
Revised April 12, 1985 Revises definition
Revised September 11, 1987 Revises definition and minimum qualifications
Revised May 1, 1990 Revises definition and minimum qualifications, adds distinguishing characteristics, title change (formerly Disability Claims Adjudicator 2
New class code: (formerly 47890) effective July 1, 2007