Workers' Compensation Claims Examiner

Job Description

Responsibilities:

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• Receive, review, and process first reports of injury, notices of loss, and workers’ compensation claims in accordance with applicable laws, regulations, policies, and procedures.
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• Investigate and evaluate workers’ compensation claims to determine compensability and injured worker entitlement to medical and related benefits.
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• Administer and manage medical-only workers’ compensation claims from inception through closure, ensuring timely and accurate claim handling.
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• Collect, analyze, and evaluate claim-related information, including medical records, employment records, witness statements, treatment plans, billing documentation, and other supporting evidence.
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• Review medical evidence and documentation to assess the appropriateness of treatment, medical necessity, work restrictions, and return-to-work opportunities.
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• Conduct required claim contacts, including 24-hour four-point contacts with injured workers, supervisors, medical providers, and other stakeholders, and document all claim activities in the claims management system.
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• Develop and document factual findings, claim analyses, and recommendations to support claim determinations and benefit decisions.
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• Communicate and coordinate with injured workers, agency representatives, healthcare providers, legal counsel, nurse case managers, and other stakeholders regarding claim status, treatment plans, and return-to-work efforts.
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• Coordinate medical appointments, independent medical evaluations, transportation services, and follow-up care when medically necessary.
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• Assess maximum medical improvement (MMI) status, work capabilities, and ongoing treatment needs based on medical evidence and provider recommendations.
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• Draft notices, correspondence, claim determinations, and other documents related to the administration and adjudication of workers’ compensation claims.
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• Maintain complete, accurate, and timely claim files and documentation in accordance with established records management requirements.
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• Research claim files, historical records, applicable laws, regulations, policies, and procedures to support claim investigations and determinations.
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• Manage assigned caseloads to ensure compliance with performance standards, statutory requirements, and customer service expectations.
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• Participate in claim reviews, settlement discussions, mediations, hearings, and other administrative proceedings, and provide testimony or supporting documentation as required.
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• Provide professional and responsive customer service while maintaining confidentiality and safeguarding sensitive medical, financial, and employment information.
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• Perform other related duties as assigned in support of the Public Sector Workers’ Compensation Program
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Qualifications:

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• Extensive years of progressively responsible claims handling experience including at least three (3) years of workers' compensation claims adjusting experience.
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• Knowledge of workers’ compensation laws, regulations, investigations, reserving, case management, and claim adjudication.
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• Ability to analyze medical evidence and make claim determinations.
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• Experience participating in hearings, mediations, or settlement conferences.
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• Knowledge of medical terminology and treatment review.
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• Strong written and verbal communication skills.
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• Proficiency with Microsoft Office applications and claims management systems.
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• Ability to handle confidential and sensitive information with discretion.
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