Workers' Compensation Claims Examiner

Job Description

Job Description

Workers' Compensation Claims Examiner

Labor Category: Workers' Compensation Claims Examiner

Location: Washington, DC

About the Role:

The Workers' Compensation Claims Examiner is responsible for receiving, investigating, and administering workers' compensation claims from inception through closure. This position evaluates compensability, reviews medical and employment records, and coordinates with injured workers, providers, and other stakeholders to support timely and accurate claim decisions. The ideal candidate has strong analytical skills, sound judgment, and experience managing a claims caseload in a fast paced environment.

Minimum Qualifications:

Bachelor's degree and two years of workers' compensation claims adjusting experience, or eight years of progressively responsible claims handling experience including at least three years of workers' compensation claims adjusting experience.

Knowledge of workers' compensation laws, regulations, investigations, reserving, case management, and claim adjudication.

Strong written and verbal communication skills.

Proficiency with Microsoft Office applications and claims management systems.

Preferred Qualifications:

Experience participating in hearings, mediations, or settlement conferences.

Knowledge of medical terminology and treatment review.

Ability to handle confidential and sensitive information with discretion.

Responsibilities:

Receive, review, and process first reports of injury, notices of loss, and workers' compensation claims.

Investigate and evaluate claims to determine compensability and entitlement to medical and related benefits.

Administer and manage medical only workers' compensation claims from inception through closure.

Collect, analyze, and evaluate claim related information including medical records, employment records, witness statements, and treatment plans.

Review medical evidence to assess appropriateness of treatment, medical necessity, work restrictions, and return to work opportunities.

Conduct required claim contacts, including four point contacts with injured workers, supervisors, and medical providers, and document activities in the claims management system.

Develop factual findings, claim analyses, and recommendations to support claim determinations and benefit decisions.

Communicate and coordinate with injured workers, agency representatives, healthcare providers, legal counsel, and nurse case managers regarding claim status and treatment plans.

Coordinate medical appointments, independent medical evaluations, and follow up care when medically necessary.

Assess maximum medical improvement status, work capabilities, and ongoing treatment needs.

Draft notices, correspondence, and claim determinations related to the administration of workers' compensation claims.

Maintain complete, accurate, and timely claim files in accordance with records management requirements.

Manage assigned caseloads to ensure compliance with performance standards and statutory requirements.

Participate in claim reviews, settlement discussions, mediations, and hearings, providing testimony or documentation as required.

Provide professional and responsive customer service while maintaining confidentiality of sensitive information.

Perform other related duties as assigned.

Skills:

Strong analytical and investigative skills are essential for evaluating claims and making sound determinations. Knowledge of workers' compensation law and medical terminology supports accurate case handling and communication with providers. Excellent written and verbal communication skills enable clear interaction with injured workers, agency staff, and legal representatives. Strong organizational skills and attention to detail support accurate documentation and caseload management.