Workers' Comp Claims Examiner

General Job Information

Job Summary

This position is located in the DC Office of Risk Management (DCORM), Public Sector Workers’ Compensation. This position is established to provide claims management support of the Public Sector Workers' Compensation Program (PSWCP), which is a system of benefits provided by law for workers who have job-related injuries or illnesses.

The primary purpose of this position is to respond to workplace injuries with the best, and most appropriate medical care, and to return employees back to work as soon as medically possible.

Incumbent serves as a Workers’ Compensation Claims Examiner, responsible for providing first-line support on a broad range of medical only workers’ compensation cases which includes controversial factual and medical issues.

Incumbent receives guidance from higher grade level examiners on difficult and controversial issues.

Duties and Responsibilities

Receives first notices of loss from District Government employees who seek to report and / or file claims for injuries sustained while serving in the scope of their employment with the District of Columbia.

Determines an injured worker’s entitlement to Workers’ Compensation benefits, and exclusively administers medical only claims.

Collects supporting data and analyzes information to make decisions regarding appropriateness of billing and treatment plan.

Receives and evaluates all medical evidence, reports, and medical documentation in support of the claim. Develops facts and evidence in making initial determination on medical only claims.

Researches electronic files for source documentation used to determine medical only claim status or issues as needed and / or requested.

Schedules appointments and follows-up on progress; assesses maximum medical improvement target date(s). Arranges transportation services for claimants to and from appointments or surgery based upon medical necessity.

Conducts 24hr 4-point contact to Injured Worker, Injured Worker’s Supervisor, Healthcare Provider, and Nurse Case Manager, after injury has been reported.

Records statements on all incoming claims. Follows guidance issued by management regarding proper adjudication of the claim.

Requests proper documentation from legal counsel when appropriate. Drafts Notices of Determinations to be issued to injured workers regarding the outcome of their claim for Workers’ Compensation benefits.

Administers medical benefits on accepted Workers’ Compensation claims. Manages a caseload of medical only claims from inception to resolution.

Maintains open and closed claims within the claims management system. Attends agency claim review sessions and assists in trials and claims mediation sessions.

Communicates with medical providers to request clarification on conflicting medical opinions and assesses to determine which injured workers require an additional medical examination.

Communicates claims activity and claims processes with the claimant. Prioritizes and maintains professional customer service with injured workers, medical professionals, and the public-at-large.

Qualifications and Education

Specialized experience is experience that is directly related to the line of work of the position and has equipped the applicant with the knowledge, skills, and abilities to successfully perform the duties of the position.

To be creditable the incumbent must possess at least one (1) year of specialized experience equivalent to the next lowest grade level in the normal line of progression.

It is highly desired for the candidate to possess a minimum of two years of hands-on experience in claims management or workers' compensation.

Licenses and Certifications

None

Working Conditions / Environment

The work is typically performed in an office setting, however, the incumbent may from time to time be required to perform duties outside of the office.

Other Significant Facts

Tour of Duty : Monday- Friday 8 : 30am- 5 : 00pm

Pay Plan, Series and Grade : CS-0991-09

Promotion Potential : No known promotion potential

Collective Bargaining Unit : This position is not covered under a collective bargaining unit.

Duration of Appointment : Career Service Term Appointment Not-To-Exceed (NTE) 13 months. A Term employee does not acquire permanent status on the basis of his / her term appointment.

Continued employment under this appointment is contingent upon availability of funding.

Position Designation : The incumbent of this position will be subject to enhanced suitability screening pursuant to Chapter 4 of DC Personnel Regulations, Suitability Security Sensitive.

EEO Statement : The District of Columbia Government is an Equal Opportunity Employer. All qualified candidates will receive consideration without regard to race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, family responsibilities, matriculation, physical handicap, or political affiliation.