Workers Compensation Claims Examiner

The Workers Compensation Claims Examiner is responsible for managing and adjudicating workers' compensation claims by reviewing injury reports, investigating claims, evaluating medical evidence, and coordinating with various stakeholders to ensure proper claim handling and benefit determination. This role requires strong knowledge of workers' compensation laws, medical terminology, and claims management processes to support injured workers and maintain compliance with legal and organizational standards. Responsibilities:

• Receive, review, and process first reports of injury, notices of loss, and workers' compensation claims in compliance with laws and policies.
• Investigate and evaluate claims to determine compensability and entitlement to benefits.
• Administer medical-only claims from inception through closure ensuring timely and accurate handling.
• Collect and analyze claim-related information including medical records, employment documents, and witness statements.
• Review medical evidence to assess treatment appropriateness, medical necessity, work restrictions, and return-to-work opportunities.
• Conduct required claim contacts and document all activities in the claims management system.
• Develop and document factual findings, analyses, and recommendations to support claim decisions.
• Communicate and coordinate with injured workers, healthcare providers, legal counsel, and other stakeholders.
• Coordinate medical appointments, independent medical evaluations, and transportation services when necessary.
• Assess maximum medical improvement status, work capabilities, and ongoing treatment needs.
• Draft notices, correspondence, claim determinations, and related documents.
• Maintain complete, accurate, and timely claim files and documentation.
• Research laws, policies, and historical records to support claim investigations and determinations.
• Manage caseloads to ensure compliance with performance standards and statutory requirements.
• Participate in claim reviews, settlement discussions, mediations, hearings, and provide testimony or documentation as needed.
• Provide professional, confidential customer service safeguarding sensitive information.
• Perform other related duties supporting the Public Sector Workers' Compensation Program.

• Bachelor's degree and two years of workers' compensation claims adjusting experience, or eight years of progressively responsible claims handling experience including three years in workers' compensation claims adjusting.
• Knowledge of workers' compensation laws, regulations, investigations, reserving, case management, and claim adjudication.
• Ability to analyze medical evidence and make claim determinations.
• Experience with hearings, mediations, or settlement conferences.
• Knowledge of medical terminology and treatment review.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office and claims management systems.
• Ability to handle confidential and sensitive information with discretion.

• Experience coordinating with nurse case managers and legal counsel.
• Familiarity with independent medical evaluations and transportation coordination.
• Demonstrated ability to manage complex caseloads effectively.

• Must maintain confidentiality and safeguard sensitive medical, financial, and employment information.
• May be required to participate in hearings, mediations, and provide testimony.

• Standard work schedule with potential requirements for attendance at administrative proceedings as needed.