Workers' Compensation Claims Examiner

Introduction

Our Client is hiring a Workers' Compensation Claims Examiner on behalf of its client, a District of Columbia government agency responsible for administering the District's workers' compensation, safety, and risk management programs. The Workers' Compensation Claims Examiner receives, investigates, and adjudicates workers' compensation claims, determines compensability and benefit entitlement, manages medical only claims from inception through closure, and coordinates with injured workers, providers, and agency stakeholders to support timely claim resolution and return to work efforts.

Responsibilities

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

Requirements

Required Qualifications

• Bachelor's degree and two (2) years of workers' compensation claims adjusting experience, or eight (8) years of progressively responsible claims handling experience including at least three (3) years of workers' compensation claims adjusting experience.
• Knowledge of workers' compensation laws, regulations, investigations, reserving, case management, and claim adjudication.
• Ability to analyze medical evidence and make claim determinations.
• Experience participating in hearings, mediations, or settlement conferences.
• Knowledge of medical terminology and treatment review.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office applications and claims management systems.
• Ability to handle confidential and sensitive information with discretion.

Additional Requirements

• Selected candidates must successfully complete a local criminal history record check within the District of Columbia and a national criminal history record check through an FBI approved channeler, including fingerprinting, in accordance with D.C. Code Section 4-1501.03.
• Selected candidates must participate in an orientation with the agency Human Resources Officer covering standards of conduct, dress code, cyber security, and ethics, and must complete assigned online training as requested.
• Selected candidates must safeguard the integrity, security, and confidentiality of all personnel information and records in compliance with the Electronic District Personnel Manual, Chapter 31, Records Management and Privacy of Records.
• Selected candidates are responsible for their own transportation to and from the duty location and may not bill for transportation time, breaks, or lunch breaks.
• Selected candidates may not represent themselves as employees of the District of Columbia at any time.
• Selected candidates must record time worked through a web based timekeeping system for weekly review and approval by the client.

How to Apply

Qualified candidates should submit a current resume in Microsoft Word or PDF format to with the job title in the subject line. Resumes must state the start date, end date, and total number of years or months served in each position held.