Worker's Compensation Claims Examiner

Job Summary

Performs varied and difficult professional and technical duties in adjusting, analyzing, investigating and resolving the City's workers' compensation claims.

Representative Duties

Reviews, examines and adjusts workers’ compensation claims filed by City employees for injuries and illnesses.

Establishes claims reserve levels and verifies documentation and accuracy. Monitors reserves for appropriate changes as necessary.

Authorizes appropriate payments of workers’ compensation benefits within pre-established authorization limits. Reviews and processes bills for payment in accordance with established fee schedules and contractual agreements with providers of service.

Assists in the investigation of claims for compensability and subrogation issues.

Contacts employees to explain benefits and legal rights under the California Labor Code and applicable City policies and Memorandums of Understanding provisions.

Authorizes hospitalization, surgery and other types of medical treatment as required.

Coordinates and monitors providers of service such as legal counsel and medical and vocational rehabilitation professionals.

Reviews and processes a variety of claim file documents, identifies issues and ensures adherence to California Labor Code and regulatory requirements.

Coordinates the resolution of claims by preparing legal documents, attending conferences and hearings and negotiating settlements within specific limits of authority.

Computes all types of indemnity payments, including calculation of temporary and permanent disability rates.

Manages claim progress. Assists in the development of strategies on assigned cases.

Files excess insurance notices and claims.

Monitors City employee salary continuation benefits in conjunction with disability status.

Assigns claims duties to the Workers’ Compensation Claims Assistant.

Performs other related duties as assigned.

Requirements

Knowledge, Abilities and Skills

Knowledge of:

California workers’ compensation laws and the procedures and regulations of the Administrative Director, Division of Workers’ Compensation.

Relevant workers’ compensation case law.

Investigation and settlement techniques and practices.

Medical terminology, vocational rehabilitation requirements and procedures of claims management and control.

Claim reserving within statutory guidelines.

Excess insurance reporting requirements.

Advanced permanent disability rating.

Ability to:

Learn and understand the City’s policies and practices related to workers’ compensation and disability retirements, including applicable Memoranda of Understanding provisions.

Organize and manage accurate files and records.

Understand, interpret and apply State Labor Code and workers’ compensation case law.

Clearly explain rules, procedures, policies and claims decisions to a variety of individuals, including employees, supervisors and management staff.

Learn specialized computer software applications.

Communicate effectively orally and in writing.

Work under the pressure of competing deadlines.

Work independently with frequent interruptions.

Provide effective customer service.

Establish and maintain effective and cooperative working relationships.

Skill in:

Reading, writing and communicating in English at an appropriate level.

The operation of personal computers, specialized software applications related to claims database, spreadsheet and word-processing, and the operation of other standard office equipment.

Dealing effectively with a variety of employees/individuals at different organizational levels and the public using tact and discretion.

Education, Training and Experience

Graduation from high school or equivalent supplemented by college level course work in insurance, business, public administration or a related field. A Bachelor’s degree from an accredited college or university in Public or Business Administration, Human Resources Management or a related field is desirable.

Three years of extensive and progressively responsible experience as a journey-level workers’ compensation claims examiner.

Public sector and/or self-insured employer workers’ compensation claims adjusting experience is desirable.

Licenses and Certificates:

Must obtain a State of California Self-Insurance Plans Administrator Certificate within six months of employment.

Possession of a valid Class C driver license.

Supplemental Information

How to Apply:

Applicants must submit a clear, concise, completed on-line City Application along with any required supplemental application materials with the Human Resources Department by the filing deadline. If you do not submit your on-line application by the filing deadline, you will not be considered for this position. Please note, applications may be rejected if incomplete. Resumes, CVs and cover letters are not reviewed as part of the application screening process.

If you would like for your education to be considered, you must attach a copy of your college level transcripts or diploma to your online application. Applicants who indicate receipt of college level coursework or degree from a foreign institution must provide United States credential equivalency verification along with a copy of your college diploma/transcripts. All materials must be received in the Human Resources Department no later than the filing deadline. Failure to do so may result in your application being evaluated without the education being considered.

Selection Process:

All applicants must submit clear, concise and complete information regarding your work history and qualifications for the position. All applicants will be reviewed and only those applicants determined to be most qualified on the basis of experience, training and education, as submitted, will be invited to participate further in the selection process.

Testing may consist of a combination of any of the following and is subject to change as needs dictate:

Training and Experience Evaluation
Writing Project

Oral Interview

If three or more qualified City employees apply and pass the examination, a promotional list will be established in addition to an open-competitive list. If fewer than three qualified City employees pass the examination, the appointing authority, in accordance with the City's civil service rules and regulations, can decline to use a promotional list, in which case a promotional list will not be established for this position.

Background Investigation:

Candidates who have successfully completed all prior phases of the selection process will be subject to a thorough background investigation.

Inclusion & Diversity Statement

The City of Santa Monica is a progressive, inclusive and culturally rich community. As leaders in public service, we strive to be an employer of choice by attracting and retaining a highly talented workforce where people of diverse races, religions, cultures and lifestyles thrive. Our goal is to create a welcoming and inclusive environment where our staff are empowered to perform at their highest level and where their differences make a positive impact.

The City is an equal opportunity employer and strives to build balanced teams from all walks of life without regard to race, color, ethnicity, religion, national origin, age, sex, sexual orientation, gender identity, marital status, ancestry, disability, genetic information, veteran status, or any other status protected under federal, state and/or local law. We aim to create a workplace that celebrates and embraces the diversity of our employees. Join us!

Special assistance with the application and examination process is available, upon request, for persons with disabilities. Call (310) 458-8246, TDD (310) 458-8696 (Hearing Impaired Only).

Please note the request for reasonable accommodations must be made to Human Resources at least three work days prior to the examination.

The City's liberal fringe benefits for full-time employment include sick leave, holiday and vacation pay, the Public Employees Retirement System, medical, dental and vision insurance, credit union, deferred compensation, tuition reimbursement, Dependent Care Assistance Plan and Marine Park Childcare Center.

Closing Date/Time: 9/19/2024 5:30 PM Pacific

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Santa Monica, California United States View Map