Workers' Compensation Claims Representative

City of Sacramento • Sacramento, CA

2d • Hybrid

About The Position

Under general supervision, the Workers' Compensation Claims Representative performs a wide variety of responsible duties in claims adjusting related to the City's self-administered Workers' Compensation Program; provides timely Workers' Compensation benefits pursuant to State of California laws; investigates, evaluates, and settles Workers' Compensation claims against the City of Sacramento; attends mandatory settlement conferences, court hearings, and meetings. This exempt classification is populated with multiple incumbents. The Workers' Compensation Claims Representative performs the entire range of specialized duties requiring a thorough knowledge of all aspects of the Workers' Compensation Program. When filled from the outside, significant prior experience in adjusting Workers' Compensation claims is required.

Requirements

• State of California Workers' Compensation laws, administrative regulations, and claims adjusting procedures.
• Principles and practices of permanent disability rating, utilization review program, independent medical review program, independent bill review program, supplemental job displacement benefits program, return to work program and disability management programs.
• Principles and practices of reserving and excess carrier reporting.
• Medical and legal terminology relating to Workers' Compensation matters.
• Oral presentation techniques.
• Evaluate permanent disability.
• Use of computers, computer applications, and software.
• Interpret, explain, and apply Workers' Compensation laws and administrative rules and regulations.
• Analyze complex data, including medical reports, and make appropriate decisions.
• Make accurate arithmetical computations.
• Speak and write effectively.
• Establish and maintain effective relationships with injured employees and their families, attorneys, and physicians.
• Three years of Workers' Compensation claims adjusting experience in an insurance company, third-party administrator, or self-insured employer.
• Possession of an Associate's Degree or 60 semester units or equivalent quarter hours from an accredited college or university with major course work in public or business administration, economics, accounting, human resources, or a related field.
• Possession of an Experienced Claims Examiner designation is required at time of appointment, per California Insurance Code Section 11761.
• Possession of, or ability to obtain by time of appointment, required post-designation training, pursuant to is required at time of appointment, per California Insurance Code Section 11761 and California Code of Regulations, Title 10, Sections 2592.02, 2592.03, 2592.04, and 2592.05.

Nice To Haves

• Experience working with first responder populations, including police and fire personnel.
• Understanding of the unique medical, operational, and return-to-work considerations associated with these roles.
• Public agency experience is desirable.
• Possession of certificate proving successful completion of the Self-Insurance Administrator's Examination may substitute for the required education.

Responsibilities

• Reviews accident and injury reports and Doctor's First Report of Injury forms to determine proper actions under Workers' Compensation laws and regulations; obtains background information; and opens and adjusts claims; pays temporary disability, permanent disability, and life pension benefits to injured employees; or, pays death benefits to dependents; reviews and pays related medical bills; reviews and pays expenses incurred to defend the City in contested claims; and verifies mileage payment requests, pharmacy reimbursements, and other bills.
• Establishes and maintains monetary case reserves to cover medical costs and projected miscellaneous and compensation costs; prepares written requests for settlements; settles litigated cases that do not require a defense attorney and advises as appropriate; reviews cases for subrogation potential and files related actions.
• Computes permanent disability case ratings and awards; coordinates benefits with other City benefits; prepares information for submission to the Workers' Compensation Appeals Board, Disability Evaluation Unit, and Administrative Director; files appropriate actions such as answers, declarations, pleadings and objections.
• Communicates verbally and in writing with injured employees, their departments, physicians, dependents, attorneys, City safety representatives, Workers' Compensation Appeals Board members, and other interested parties; reviews established claims periodically to prompt action and closure, and/or settlement.
• Sets medical evaluations and coordinates return to work, interactive process, utilization review, independent medical review, and independent bill review; attends mandatory settlement conferences, hearings, and meetings relevant to cases.
• Provides exceptional customer service to those contacted in the course of work.

Benefits

• Intermittent remote work (with supervisor approval and residing within the Sacramento region or ability to regularly report to a City of Sacramento physical worksite with little notice).

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree