Supervising Worker's Compensation Claim Examiner

Job Summary

Reviews, examines and adjusts workers' compensation claims filed by City employees for job related injuries and illnesses and develops appropriate plans of action. Establishes and monitors claims reserve levels. Reviews claim documentation for compensability and subrogation issues or potential fraud or abuse. Coordinates authorization of medical treatment. Computes indemnity benefits and related payments. Supervises, assigns and reviews the work of professional, technical, and clerical support staff.

SUPERVISION

Works under the general supervision of the Risk Manager who assigns and outlines work assignments, periodically reviews work in progress and reviews completed work. Exercises administrative and technical supervision over professional, technical and clerical support staff, outlining work assignments, periodically reviewing work in progress and upon completion.

Representative Duties

Supervises the daily operations of the Workers' Compensation Claims Unit of the Risk Management Division.

Provides guidance to the examiner staff in proper techniques of claims handling in the areas of investigation, reserve setting, claim management, and claim settlement.

Ensures that staff assigned to the Workers' Compensation Unit comply with applicable laws, departmental policies and procedures, and customer service standards; coordinates and presents settlement strategy recommendations to the Risk Manager.

Coordinates file reviews with legal counsel and the Risk Manager.

Trains, assigns, and evaluates the work of assigned staff.

Reviews, examines, and adjusts workers' compensation claims filed by City employees for job related injuries and illnesses. Establishes and monitors claims reserves levels and verifies documentation for accuracy.

Authorizes, reviews, and processes bills and payments based upon appropriate fee schedules, contractual agreements, and pre-established authorization limits.

Reviews claim documentation for compensability and subrogation issues or potential fraud or abuse.

Explains workers' compensation benefits and legal rights to employees based upon applicable federal, state, and City code and policies.

Coordinates medical treatment authorization with the City's utilization review provider for approval of diagnostic procedures, hospitalization, and other medical services. Monitors and coordinates the work of service providers.

Reviews and processes claim file documents.

Coordinates the implementation and upgrades of Workers' Compensation related software applications with the Information Systems Department and outside vendors.

Prepares legal referrals and documents, and negotiates appropriate settlement of claims and liens within authorization limits.

Reviews and computes indemnity benefits and related payments. Ensures claims are in compliance with internal performance goals and standards. Monitors and coordinates employee salary continuation and safety employee benefits in conjunction with disability payments, and coordinates payroll record timekeeping, as applicable.

Files reports in compliance with the City's excess insurance or pooling authority guidelines.

Gathers and analyzes data and prepares written reports related to claims.

Represents the Workers' Compensation Administrator in his/her absence in court and at hearings and various meetings.

Coordinates injured workers' return-to-work in compliance with the City's transitional duty program.

Performs other related duties as assigned.

Requirements

KNOWLEDGE, SKILLS, AND ABILITIES

Knowledge of:

Relevant workers' compensation laws, procedures and regulations

Relevant workers' compensation case law

Medical terminology, vocational rehabilitation requirements and procedures of claims management and control

Procedures of claims adjusting and management

Investigation and settlement techniques and practices

Claim reserving within industry standards

Principles of permanent disability rating

General practices used in claims related programs

General principles of investigation

Supervisory principles and practices

Effective supervision and training techniques

Effective customer service techniques

Specialized software applications related to claims databases, spreadsheets and word-processing

Ability to:

Select, supervise, train, and evaluate assigned staff

Learn and understand the City's policies and practices related to workers' compensation and claim handling procedures, practices, and policies

Analyze and explain the basis for claims decisions to employees, supervisors, and management staff

Process claims payments and perform financial record keeping tasks related to claims.

Organize and manage accurate files and records

Communicate effectively, both orally and in writing

Learn specialized computer software applications

Work independently with frequent interruptions and under the pressure of competing deadlines

Resolve difficult problems involving employees at different organizational levels using tact and discretion

Provide effective customer service

Establish and maintain effective and cooperative working relationships with City employees and the general public

Operate standard office equipment, including personal computers

REQUIREMENTS

Minimum Qualifications:

Option A:

Education: Graduation from an accredited college or university with an associate degree or 60 semester units or the equivalent of college-level coursework.

Experience: Four years of recent, paid progressively responsible journey-level workers' compensations work experience, including two years of experience leading and coordinating the work of others. One year of leading and coordinating the work of others and successful completion of the City of Santa Monica's Pre-Supervisory Academy may substitute for the two years of leading and coordinating experience.

Public sector and/or self-insured employer workers' compensation claims experience is desirable.

Option B:

Education: Graduation from an accredited college or university with a bachelor's degree.

Experience: Two years of recent, paid progressively responsible journey-level workers' compensations work experience and leading and coordinating the work of others. One year of leading and coordinating the work of others and successful completion of the City of Santa Monica's Pre-Supervisory Academy may substitute for the two years of leading and coordinating experience.

Public sector and/or self-insured employer workers' compensation claims experience is desirable.

Licenses and Certificates:

Possession of a valid class C driver license or the ability to utilize an alternative method of transportation when needed to carry out job-related essential functions.

Must possess or successfully obtain the California Self-Insurance Plans Administrator Certificate within 6 months from the date of hire.