State of Washington Classified Job Specification
WORKERS' COMPENSATION ADJUDICATOR 2
In the Department of Labor and Industries, in Claims Administration, adjudicates and manages a caseload of compensable workers' compensation claims; or in Crime Victims, adjudicates and manages a caseload of crime victims' claims; or in Self-Insurance, adjudicates, manages, monitors and regulates self-insured employers' workers' compensation claims for compliance with the Industrial Insurance Laws.
Positions assigned to this class which are responsible for the management of compensable claims, involve more than 14 days of time loss from work with level 2 complexity factors or level 2 complexity factors in crime victims.
NOTE: Level 2 complexity factors are determined by the Labor and Industries claims assignment system matrix.
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 decisions, 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;
Determines 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 occupational 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 courts; 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.
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.
A Bachelor's degree.
One year of experience in adjudication 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
New Class (47640, Worker’s Compensation Claims Specialist), Amended: Adopted Effective 09/13/1985; Definition language amended.
Revises definition and minimum qualifications, adds distinguishing characteristics, title change (formerly Worker's Compensation Claims Specialist): 5-1-90
Class code change (formerly 4764): 7-1-91
New class code: (formerly 47881) effective July 1, 2007