Claims Examiner

Job Title

Under general supervision, examines and adjusts claims for Workers' Compensation benefits; monitors claim expenditures; communicates with physicians, supervisors, employees and attorneys regarding illness or injury related to employment; and performs other related duties.

Supervision Received/Exercised

Works under the general supervision of the Risk Manager and/or Worker's Compensation Claims Administrator. May exercise supervision over subordinate personnel, including the Claims Technician.

Primary Duties and Responsibilities

The following essential functions are those that are critical, integral, necessary, crucial, primary and fundamental to the job. Incumbents who possess the requisite skill, experience, education, and other job-related requirements of a position are expected to perform the essential functions of the job with or without a reasonable accommodation.

The following duties ARE NOT intended to serve as a comprehensive list of all duties performed by all employees in this classification, only a representative summary of the primary duties and responsibilities. Incumbent(s) may not be required to perform all duties listed and may be required to perform additional, position-specific duties.

• Reviews, examines and adjusts Workers' Compensation claims.
• Receives and records all claims and determines compensability.
• Authorizes medical treatment and/or change of physician utilizing California State Workers' Compensation Law.
• Computes and authorizes payments according to California Labor Code, including medical bills, temporary and permanent disability payments.
• Advises employees and dependents of entitlement to Workers' Compensation benefits under state law and City policies.
• Arranges special investigations and medical examinations including return to work exams.
• Advises departments regarding procedures and reporting deadlines involving work related injuries.
• Contacts injured employee to explain benefits and legal rights under the Labor Code.
• Prepares subrogation and litigation cases and corresponds with doctors and attorneys on litigated cases.
• Serves as custodian of records; produces record and attests to validity under the direction of the court by subpoena.
• Compiles pertinent facts, makes thorough analyses, and arrives at sound decisions.
• Maintains and enforces all aspects of security and confidentiality of records and information.

Performs other duties as assigned or required.

Minimum Qualifications

Education and Experience:

Possession of a Bachelor's degree from an accredited college or university in Business Administration or a related field, AND two (2) years of experience adjusting workers' compensation claims with a public agency or third-party administrator; OR an equivalent combination of education and experience. Two (2) years of supervisory experience is highly desirable.

Required Licenses or Certifications:

Must possess a valid California Class C Driver's License.

Required Knowledge of:

City organization, operations, policies and procedures.

City Code, City Ordinances, and Standard Operating Manual.

State of California Labor Code and Workers' Compensation law.

Medical terminology, anatomy, and technical terminology used in the medical profession related to the cause and treatment of occupational injuries and diseases.

Investigative techniques, methods and procedures.

Vocational rehabilitation processes and programs.

MS Office computer applications.

Required Skill in:

Compiling pertinent facts, making thorough analyses or Workers' Compensation claims and arriving at sound decisions.

Understanding, interpreting and applying State Labor Code, Workers' Compensation Law, and City regulations.

Establishing and maintaining cooperative working relationships with co-workers.

Operating a personal computer utilizing a variety of business software.

Effective communication, both verbal and written.

Physical Demands / Work Environment:

Work is performed indoors in an office setting.

Work requires frequent light lifting, sorting, filing, typing and driving.

Moderate finger dexterity and near vision is required.

May be exposed to minor amounts of dust.