Workers’ Compensation Time Loss Adjudicator

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JOB TITLE: Workers’ Compensation Time Loss Adjudicator                 FLSA STATUS:      Non-Exempt

DEPARTMENT: Claim Services                                                             

REPORTS TO: Assistant Director Client Services & Compliance  

PAY RANGE: $65,000 to $90,000

HYBRID WORK OPPORTUNITY AVAILABLE

POSITION SUMMARY:   

The Workers’ Compensation Time Loss Adjudicator adjudicates and manages the Self-Insured Public Hospital District and Washington Hospital Workers’ Compensation time loss and treatment only claims.  This position regulates self-insured workers’ compensation claims for compliance with the Industrial Insurance Laws Title 51 (RCW), Medical Aid Rules and other statutes related to industrial insurance.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  • Adjudicate workers’ compensation claims to interpret facts and apply laws to determine claim validity and is responsible for the ongoing appropriate and timely claim management activities necessary to bring resolution at the earliest possible time in a cost-effective manner.
  • Calculate monthly gross earnings and daily time loss rates for the purposes of issuing accurate and timely benefit payments.
  • Ensure initial disability benefit payments are issued within 14 days of notice of receipt of claim and ongoing benefit payments are issued every 14 days.
  • Initiate and complete the 3-point contact within 48 hours of receipt of a new claim.
  • Establish initial case reserves for the life of each claim at the time of initial claim review and review case reserves every 60 days making necessary adjustments based upon anticipated indemnity, medical, vocational, legal or other costs.
  • Conduct a comprehensive file review, take appropriate actions, and complete a Claim Status Summary Report and written Plan of Action (POA) every 60 days.
  • Maintain a current claims diary, defined per performance standards.
  • Complete timely review and acknowledge receipt of claim documents, record document note entry, take appropriate action and record actions taken in response to documents received and reviewed.
  • Review claim file documents to evaluate need for ongoing disability certification, authorize or deny requests for medical treatment, surgery, diagnostic studies, transfers of medical care, refer for vocational, investigative or legal services and/or submit claim for closure.
  • Review determinative orders received from the Department of Labor & Industries for the purposes of ensuring they are accurate and represent our interpretation of the facts of the claim and file timely protests or appeals as warranted.
  • Evaluate medical reports to determine appropriate permanent partial disability awards.
  • Communicate both verbally, and in writing with Department of Labor & Industries staff, designated hospital contacts, physicians, injured workers, claimant and employer attorneys, and other stakeholders.
  • Develop and maintain a professional and positive working relationship with all stakeholders.
  • Secure, manage and direct the services of outside specialty providers (e.g., independent medical providers, vocational counselors, nurse case managers, defense counselors, and investigators).
  • Identify and update injured worker’s physical restrictions and assist clients in the return to work accommodation process; determine the need for vocational services and approve or deny formal vocational plans.
  • Investigate and pursue Third Party subrogation claims.
  • Approve medical payments on claim files on a weekly basis.
  • Prepare claims for closure with the Department of Labor & Industries or close claims in-house following appropriate procedures.
  • Complete claim status reviews with clients on a quarterly basis (telephone, web-based or onsite).
  • Work with Unemployment Program and absence management staff on joint accounts to coordinate documentation in an effort to discover fraudulent concurrent claims and reduce costs.
  • Work with designated hospital contacts answering questions, educating and updating them on an ongoing basis with regard to their assigned duties.
  • Attend and represent Washington Hospitals Services Workers’ Compensation Program at self-insured meetings, seminars and other meetings as designated.
  • Perform other duties as assigned.

SUPERVISORY RESPONSIBILITIES:  

This position has no supervisory responsibilities.

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required. 

Education/Experience:   

Bachelor’s Degree or equivalent workers’ compensation experience processing both time-loss and treatment-only claims preferred; or willing to become certified through a two-year training program.

Skills & Abilities: 

  • Familiarity with RCW 51 and WAC 296
  • Knowledge of or experience working with unemployment laws and unemployment claims
  • Demonstrated customer service and interpersonal skills
  • Must be a self-starter and innovator
  • Ability to work independently
  • Must possess strong analytical and organizational skills
  • Have or obtain a Self-Insurance Department – Approved Claims Administrator certificate within a maximum of two year’s employment at Washington Hospital Services, and maintain for duration of employment.
  • Must have access to a vehicle and the ability to travel periodically within Washington State to member hospitals.
  • Comfortable giving and receiving feedback in a constructive manner to colleagues and supervisors

Computer Skills:

Proficiency with Microsoft Office Suite including Outlook, Word, and Excel required.  Proficiency with email required.  Proficiency with workers’ compensation databases; experience with paperless systems required, familiarity with ERIC a plus.  Knowledge of computerized claims processing.

PHYSICAL DEMANDS AND WORK ENVIRONMENT:

The physical demands and work environment described below represent the activities and surroundings of the positions.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The work is typically performed in an office environment, with a moderate noise level.  The position requires working in an office environment with the usual office equipment, including copiers, fax machines, and computers. The employee is frequently required to talk and hear on the telephone and in person with individuals and groups.  The incumbent may carry materials/equipment weighing up to 25 lbs on occasion.  The incumbent is required to read and respond to documents in hard copy and electronic form.  The position requires frequent or  occasional travel within Washington State to member facilities, and on occasion, overnight travel is necessitated.

Affiliates

Contact Us

Washington State Hospital Association
999 Third Avenue
Suite 1400
Seattle, WA 98104

Map / Directions

206.281.7211 phone
206.283.6122 fax

info@wsha.org

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