State of Washington Classified Job Specification
WORKERS' COMPENSATION ADJUDICATOR 1
In the Department of Labor and Industries, adjudicates and manages a caseload of non-compensable and compensable workers' compensation claims or crime victims claims.
Positions assigned to this class which are responsible for the management of non-compensable and compensable claims, involve less than 14 days of time loss with level 1 complexity factors.
Note: Level 1 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 benefit or Crime Victim 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, with clear, concise, accurate and informative correspondence and reports; establish and maintain effective customer relations and working relationships with claimants, physicians, fellow employees, and the general public; compare past records, past and present law, Industrial Insurance Appeals Board rulings and other information, 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.
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.
Experience working with insurance claims within Labor and Industries or in claims/insurance adjusting, claims investigations, paramedical occupation, or related field will substitute, year for year, for education.
Class Specification History
June 26, 1964 Retitled from Disability Claims Adjudicator III, 4786, and specification amended
Revised October 1, 1968 Revises minimum qualifications
Revised October 12, 1979 Revises definition and general revision
Revised August 15, 1986 Revises definition, minimum qualifications, title change (formally Disability Claims Adjudicator 1)
Revised May 1, 1990 Revises definition, minimum qualifications, adds distinguishing characteristics, title change (formerly Worker's Compensation Claims Analyst)
New class code: (formerly 47880) effective July 1, 2007