State of Washington Classified Job Specification
WORKERS' COMPENSATION ADJUDICATOR 3
Class Series Concept
Positions at this level are characterized by assignments in one or more of the following areas:
• Claims Administration: Adjudicates and manages a caseload of compensable workers’ compensation claims, adjudicates third party recoveries, or determines social security offsets or pension benefit levels for claimant and beneficiaries.• Crime Victims Compensation: Adjudicates and manages a caseload of crime victims claims that are catastrophic in nature or adjudicates third party recoveries.
• Self-Insurance: Adjudicates, manages, monitors, and regulates self-insured employers’ workers’ compensation claims for compliance with the Industrial Insurance Laws.
NOTE: Level 3 complexity factors are determined by the Labor and Industries claims assignment system matrix.
Reviews and adjudicates Industrial Insurance or Crime Victim Compensation claims; interprets facts and applies RCWs, WACs, case law, policies and training resources in determining claim validity; establishes rate of compensation for allowed Industrial Insurance or Crime Victim Compensation benefit payments;
Evaluates and authorizes or denies requests for medical treatment, surgery, diagnostic studies, transfer of physicians and reimbursement of claimant's travel expenses;
Documents all authorizations or denials for medical treatment adjudicator to review for appropriate payment;
Makes decisions on requests for reopening of claims; reviews and investigates requests for accident fund benefits received after statutory time limitation;
Establishes case reserve by estimating the total cost of each claim for the life of claim based on trends; resolves disputes between employers, attorneys and the department regarding case reserve amounts; establishes new pensions for claimants and/or their beneficiaries;
Interprets medical information in a claim file including operative reports and estimates future potential medical procedures for the allowed industrial condition and related conditions; estimates claim costs avoided or reserves on specific valuation dates due to fraud;
Adjudicates protests to determinations made regarding entitlement to benefits under the Industrial Insurance Laws and provide testimony at Board of Industrial Appeal hearings;
Perform the duties of the lower level in the series;
Performs other related work as required.
Knowledge and Abilities
Ability to: Exercise mature judgment in adjudicating disability claims and counterclaims from disabled workers, 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.
A Bachelor's degree
Two years of experience in adjudicating workers’ or crime victims’ compensation insurance claims, or adjudication of time loss payments.
Successful completion of the Department of Labor and Industries Workers’ Compensation Adjudicator 2 Apprenticeship program.
One year of experience as a Workers’ Compensation Adjudicator 2.
Class Specification History
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.
Base range salary adjustment, revised definition, distinguishing characteristics, typical work, knowledge and abilities, and desirable qualifications, new class series concept, adopted June 22, 2023, effective July 01, 2023.