See Workers’ Compensation Adjudicator 1

In the Department of Labor and Industries, this is the journey level of the series. In Claims Administration, positions adjudicate and manage a caseload of compensable workers’ compensation claims.

Under general supervision, positions assigned to this class are responsible for the management of compensable claims, including more than 14 days of time loss within the level 2 complexity factors in claims administration. Positions at this level must apply appropriate sets of regulatory rules, laws, policies, procedures and processes to adjudicate claim validity, authorize medical treatment, claim closure, and determine entitlement to various compensation benefits.
NOTE: Level 2 complexity factors are determined by the Labor and Industries claims assignment system matrix.

Reviews and adjudicates Industrial Insurance claims; interprets facts and applies RCWs, WACs, case law, policies, and training resources in determining claim validity; authorizes or denies wage replacement and establishes rate of compensation for allowed Industrial Insurance benefit payments;

Analyzes the medical file, obtains clarification by ordering consultations or independent medical exams. Reviews extensive vocational reports to determine and apply outcomes regarding a claimant's ability to work;

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;

Receives and processes liens or other reductions in benefits;

Determines employability or eligibility for vocational services; refers for vocational services;

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

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, and departmental regulations applying to industrial accidents and occupational diseases, past and present, medical terms, human anatomy and physiology, 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 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 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.

Successful completion of the Workers’ Compensation Adjudicator 2 Apprenticeship program. 

AND

Three years of experience working with insurance claims, claims/insurance adjusting, claims investigations, or paramedical occupations.

OR

A Bachelor's degree.

AND

One year of experience in adjudicating workers’ or crime victims’ compensation insurance claims, or adjudication of time loss payments.

OR

Equivalent education/experience.

New Class (47640, Worker’s Compensation Claims Specialist), Amended: Adopted Effective September 13, 1985; Definition language amended.
Revises definition and minimum qualifications, adds distinguishing characteristics, title change (formerly Worker's Compensation Claims Specialist): May 1, 1990.
Class code change (formerly 4764): July 1, 1991.
New class code: (formerly 47881) effective July 1, 2007.
Base range salary adjustment, revised definition, distinguishing characteristics, typical work, knowledge and abilities, desirable qualifications, and new class series concept, adopted June 22, 2023, effective July 1, 2023