In the Department of Labor and Industries, the Workers' Compensation Adjudicator Series is a professional series that performs analysis of medical, legal, compensatory, and vocational documentation to determine entitlement to workers' compensation benefits per RCW Title 51. Progression in this class series requires successful completion of the Workers’ Compensation Adjudicator 2 apprenticeship as approved by the Washington Apprenticeship and Training Council.

In the Department of Labor and Industries, this is the entry level of the series. Positions adjudicate and manage a caseload of non-compensable and compensable workers' compensation claims; determining the validity of claims and sufficiency of medical evidence; on-going medical management, and entitlement to benefits based on work status.

Working under close supervision, positions are responsible for the management of non-compensable and compensable claims, involving 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 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 benefit;

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;

Receives and processes liens or other reduction of benefits;

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 and documents strategies to move a claim to successful closure;

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

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, psychiatric terms, drugs, prosthetic devices, and their implications; tort law pertaining to third parties.

Ability to: exercise mature judgment in adjudicating claims and counterclaims from 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 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.

OR

Four years of experience working with insurance claims or in claims/insurance adjusting, claims investigations, paramedical occupation.

OR

Equivalent education/experience.

Retitled June 26, 1964, 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.
Revised definition, distinguishing characteristics, typical work, knowledge and abilities, desirable qualifications, and new class series concept, adopted June 22, 2023, effective July 1, 2023.