Workers’ Compensation Claims Examiner

Greenlife Healthcare Staffing • Washington, DC

6d • Onsite

About The Position

Administers workers’ compensation claims from initial report through closure by investigating compensability, analyzing medical and employment evidence, making claim recommendations, coordinating services, maintaining claim records, and supporting hearings and settlements. This is a temporary, full-time position providing essential claims examination services for the Public Sector Workers' Compensation Program. The role involves receiving, reviewing, and processing claims, investigating and evaluating them to determine compensability and entitlement to benefits, and managing medical-only claims from inception through closure. The Claims Examiner will collect and analyze various types of evidence, review medical records for treatment appropriateness and work restrictions, and conduct required claim contacts. They will develop factual findings and recommendations, coordinate with various stakeholders, and manage assigned caseloads to meet performance standards. The position also involves participating in claim reviews, settlement discussions, mediations, and hearings, while protecting confidential information and providing professional customer service. Other related duties supporting the Public Sector Workers’ Compensation Program may also be assigned.

Requirements

• Bachelor’s degree and at least two years of workers’ compensation claims adjusting experience; or eight years of progressively responsible claims-handling experience, including at least three 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.
• Workers’ compensation investigation, compensability analysis, reserving, adjudication, and caseload management.
• Medical and claim-record analysis, factual findings, and written determinations.
• Claims management systems and Microsoft Office applications.
• Stakeholder coordination, hearings and mediation support, customer service, and written and verbal communication.
• Confidential and sensitive information handling.

Responsibilities

• Receive, review, and process first reports of injury, notices of loss, and workers’ compensation claims under applicable laws, regulations, policies, and procedures.
• Investigate and evaluate claims to determine compensability and entitlement to medical and related benefits.
• Manage medical-only workers’ compensation claims from inception through closure.
• Collect and analyze medical records, employment records, witness statements, treatment plans, bills, and other claim evidence.
• Review medical evidence for treatment appropriateness, medical necessity, work restrictions, and return-to-work opportunities.
• Complete required claim contacts, including 24-hour four-point contacts with injured workers, supervisors, medical providers, and other stakeholders; document activity in the claims management system.
• Develop factual findings, claim analyses, and recommendations supporting determinations and benefit decisions.
• Coordinate with injured workers, agency representatives, healthcare providers, legal counsel, nurse case managers, and other stakeholders.
• Coordinate medical appointments, independent medical evaluations, transportation services, and medically necessary follow-up care.
• Assess maximum medical improvement, work capacity, and ongoing treatment needs using medical evidence and provider recommendations.
• Draft notices, correspondence, claim determinations, and adjudication documents.
• Maintain complete and timely claim files; research claim histories, laws, regulations, policies, and procedures.
• Manage assigned caseloads to meet performance standards, statutory requirements, and customer-service expectations.
• Participate in claim reviews, settlement discussions, mediations, hearings, and administrative proceedings; provide testimony or supporting documents when required.
• Protect confidential medical, financial, and employment information and provide professional customer service.
• Perform other related duties supporting the Public Sector Workers’ Compensation Program.

Benefits

• Competitive Compensation: Earn $42 per hour providing essential claims examination services for the Public Sector Workers' Compensation Program.
• Comprehensive Benefits: Temporary, full-time position.
• No work on District holidays or administrative closure days.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level