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City of Torrance
Class Code: 1307

Class Designation: Civil Service

May 2005
(Revised)

Representation Unit: Certain Full-Time Salaried & Hourly Employees

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Workers' Compensation Claims Examiner

Definition

Under direction, performs professional and technical duties including adjusting, analyzing and resolving claims for workers' compensation benefits; and performs related work as required.

Distinguishing Characteristics

This classification encompasses the journey level to the advanced journey/senior level. Incumbents at the journey level class perform a full range of complex tasks and work within a framework of established procedures with only occasional instruction or assistance. Work is reviewed upon completion and for overall results. Interpretation of general administrative or operational policies is necessary.

Incumbents at the advanced journey/senior level perform the most complex tasks and possess a significant level of specialized, technical and functional expertise. Incumbents exercise independent judgement in the performance of duties, with great latitude in determining work methods and assignment requirements. Work may require the development of recommendations consistent with directives, policies and regulations. Incumbents at this level can assume responsibility for the program when the Workers' Compensation Administrator is not available.

Supervision Exercised/Received

Receives direction from the Workers' Compensation Administrator; may provide technical direction to Claims Technicians or other lower-level staff.

Examples of Essential Duties

The following duties represent the principal job duties; however, they are not all inclusive.
When assigned to journey level positions:
  • Reviews, examines and adjusts workers' compensation claims.
  • Establishes claims reserve levels and verifies documentation and accuracy and monitors reserves for appropriate changes as necessary.
  • Authorizes hospitalization, surgery, and other types of treatment as required.
  • Authorizes appropriate payments of medical bills, temporary and permanent disability compensation and death benefits within pre-established authorization limits.
  • Reviews and processes bills for payment in accordance with established fee schedules and contractual agreements with provides of service.
  • Consults with and monitors providers of service such as legal counsel and medical and vocational rehabilitation professionals.
  • Completes and maintains records and reports required for workers' compensation claims.
  • Explains benefits and legal rights under applicable codes, City policies and Memoranda of Understanding provisions to employees.
  • Computes Permanent Disability ratings.
  • Coordinates the resolution of non litigated claims by preparing legal documents such as Stipulations with Request for Award and Compromises and Release Agreements, attending conferences and hearings and negotiating settlements within specific limits of authority.
  • Reviews, processes and prepares a variety of claim file documents, identifies issues and ensures adherence to California Labor Code and regulatory requirements.
  • Facilitates the return of injured workers by advising management of workers' compensation procedures and benefits and return to work programs.
  • Evaluates and calculates the costs of Stipulated Findings and Awards.
  • Reviews, files, and does follow-up on subrogation claims, files excess insurance claims.
  • Assists in the development of strategies on assigned cases.
  • Assists in the preparation of litigated cases.
  • In addition to the duties listed above, incumbents at the advanced journey/senior level perform the following:
  • Reviews, examines and adjusts complex, sensitive and/or catastrophic workers' compensation claims.
  • Assists in the negotiation of settlements for controversial and high cost claims.
  • Advises and makes recommendations to managers and supervisors regarding the impact regarding workers' compensation benefits.
  • Coordinates Workers' Compensation program activities and services with those of other departments and outside agencies and organizations
  • Makes recommendations' regarding departmental systems and procedures, goals and objectives, and short and long range planning.
  • May assign, review and coordinate the work of Workers' Compensation Claims staff; and train other staff members in a variety of areas.
  • Participates as a member on interdepartmental teams and committees as required.
  • Keeps abreast of current workers' compensation practices, laws and regulations, and literature.
  • Prepares various status, analytical and technical reports and correspondence.
  • Examples of Other Duties

    The following duties represent duties that are generally performed by this position, but are not considered to be principal job duties:
  • Attends division and department meetings as required.
  • Serves on various committees as appropriate.
  • Distributes notices, flyers, etc. as assigned.
  • Perform related duties as required.
  • Minimum Qualification Guidelines

    Knowledge of

  • California Workers' Compensation laws and the procedures and regulations of the Administrative Director, Division of Workers' Compensation.
  • Jurisdiction, functions, and procedures of the Workers' Compensation Appeals Board.
  • Relevant workers' compensation case law.
  • Principles and practices of negotiations and claim settlement procedures and techniques.
  • Principles and procedures used to set reserve amounts.
  • Investigation and settlement techniques and practices.
  • Medical terminology, vocational rehabilitation requirements and procedures of claims management and control.
  • City policy on light duty, modified work and safety disability retirement programs.
  • City codes and ordinances, and administrative rules and regulations affecting departmental operations.
  • Customer service techniques.
  • City and Department Mission including strategic goals and objectives.
  • General City operations.

    Ability to

  • Understand, interpret, and apply workers' compensation and disability retirement laws, regulations, and procedures 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.
  • Learn and utilize specialized computer software applications.
  • Adjust and manage workers' compensation claims.
  • Write case histories; reports, and letters.l
  • Understand, interpret, apply and explain laws, codes, regulations, policies and procedures related to the Workers' Compensation program to employees, supervisors and management staff.
  • Communicate clearly and concisely, orally and in writing.
  • Evaluate and rate permanent disability cases.
  • Establish and maintain effective working relationships with City employees, elected and appointed City officials, vendors and the public.
  • Collect and analyze data and make appropriate recommendations.
  • Work independently with frequent interruptions.
  • Shift priorities as departmental workload demands require and meet deadlines.
  • Maintain confidentiality and exercise sound judgment.
  • Understand and carry out oral and written directions.
  • Learn and utilize new skills and information to improve job performance and efficiency.
  • License or Certificate

    Must possess and maintain an appropriate, valid California driver's license.

    Incumbents appointed after January 2005 must posses and maintain a State of California Self-Insurance Plan Certificate and the appropriate certification of competency as required by the State of California

    Experience And Education

    Any combination of education and experience that provides the required knowledge and skills is qualifying. A typical way to obtain the knowledge and skills would be:

    Graduation from high school or equivalent supplemented by college level coursework in workers' compensation, insurance, business or public administration, or a related field that included a permanent disability rating course; and two years of recent progressively responsible experience adjusting workers' compensation claims.

    Special Requirements

    Performance of the essential duties of this position includes the following physical demands and/or working conditions:

    Requires the ability to exert a small amount of physical effort in sedentary to light work involving moving from one area to another; requires sufficient hand/eye coordination to perform repetitive movements, such as typing, filing, and the use of commonly used office machines and supplies; may involve extensive VDT exposure. Tasks require visual perception and discrimination as well as oral communication ability.

    Career Ladder Information

    Experience gained in this classification may serve to meet the minimum requirements for promotion to Workers' Compensation Administrator.