Claims Adjudicator

Salary: $85,202.00 - $94,047.00 Annually

Location : Spokane, WA

Job Type: Regular, Full-Time

Job Number:

Division: Operations and Technical Services

Department: Workers Compensation Cooperative, Claims

Opening Date: 06/06/2024

Purpose Statement

The job of claims adjudicator is done for the purpose of evaluating eligibility and processing workers' compensation claims in compliance with the cooperative's procedures and state regulations, documenting activities, conveying information regarding claims and benefits, providing administrative support to assigned department/program, maintaining department records, and compiling and distributing a wide variety of materials and support.

If the successful applicant is certified by Labor and Industries as a self-insured claims administrator, 100% remote work within the State of Washington will be allowed. Attending a monthly meeting in person is required.
Functions

• Adjudicates workers' compensation and related benefit claims (e.g. completing investigations, determining validity, setting reserves, calculating compensation amount, determining medical aid benefits; reaching closure, etc.) for the purpose of complying with legal requirements, cooperative agreements, and state statutes.
• Administers provisions of workers' compensation benefits agreements for the purpose of ensuring that appropriate services are provided, monitoring costs, and resolving claims in a timely manner.
• Analyzes documents (e.g. accident and injury reports, doctor's reports, vocational rehabilitation analysis, permanent disability rating, etc.) for the purpose of accurately determining benefit entitlements.
• Attends legal hearings on workers' compensation and related benefits disputes for the purpose of providing testimony and monitoring proceedings as necessary.
• Analyzes workers' compensation documentation (e.g. pharmacy and medical billings) for the purpose of identifying problem/high cost areas and processing payment, including time loss payments.
• Develops forms, letters, procedures, etc. for the purpose of ensuring provider and claimant compliance with workers' compensation trust requirements.
• Evaluates employee status (regarding claim validity, light duty release, subrogation decisions, etc.) as it pertains to workers' compensation.
• Maintains workers' compensation files and records for the purpose of documenting actions and ensuring compliance with all regulations, district rules, and legal requirements.
• Monitors status of claims (e.g. verifying information, payroll, case settlements, etc.).
• Notifies supervisor regarding issues pertaining to claims for the purpose of providing accurate and up-to-date information to support claims and administration.
• Prepares written materials (e.g. investigations, claim information, files, correspondence, etc.) for the purpose of documenting activities, providing written reference, and conveying information.
• Provides information to NEWESD and participating district personnel (e.g. payroll, personnel, workers' compensation department, etc.) for the purpose of documenting payment of bills.
• Supports assigned administrative and departmental personnel for the purpose of ensuring an efficient and effective work environment.
• Responds to questions from NEWESD participating district and non-district personnel regarding workers' compensation program or cases for the purpose of solving problems, providing information, and facilitating communication among parties.
• Assists other personnel as may be required for the purpose of ensuring an efficient and effective work environment.
• Performs related duties as assigned. Related duties may not specifically be listed but are within the general occupational series and responsibility level typically associated with the employee's classification of work.

Skills, Knowledge, and Abilities

SKILLS are required to perform multiple, technical tasks with a potential need to upgrade skills in order to meet changing job conditions. Specific skills required to satisfactorily perform the functions of the job include:

• operating standard office equipment,
• preparing and maintaining accurate records,
• planning and managing projects,
• and utilizing pertinent software.

KNOWLEDGE is required to perform algebra and/or geometry, read technical information, compose a variety of documents, facilitate group discussions, and solve practical problems. Specific knowledge required to satisfactorily perform the functions of the job includes:

• workers' compensation programs,
• state workers' compensation regulations and laws,
• medical and legal terminology related to workers' compensation,
• Industrial Insurance Laws,
• Medical Aid Rules and Fee Schedule,
• and appeals procedures.

ABILITY is required to schedule activities and meetings, routinely gather, collate, and classify data, and use basic, job-related equipment. Flexibility is required to work with others in a wide variety of circumstances, analyze data utilizing defined but different processes, and operate equipment using defined methods. Ability is also required to work with a diversity of individuals and groups, work with data of varied types and purposes, and utilize specific, job-related equipment. In working with others, independent problem solving is required to analyze issues and create action plans. Problem solving with data requires analysis based on organizational objectives and problem solving with equipment is limited. Specific abilities required to satisfactorily perform the functions of the job include:

• working independently,
• communicating with diverse groups,
• working with frequent interruptions,
• working with detailed information/data,
• maintaining confidentiality,
• establishing effective relationships,
• and adapting to changing work priorities.

General Requirements

Responsibility

Responsibilities include:

• working with immediate supervision,
• providing information and advising others,
• and operating within a defined budget.

There is continual opportunity to impact the agency's services.

Working Environment

The usual and customary methods of performing the job's functions require the following physical demands: some lifting, carrying, pushing, and/or pulling, and significant fine finger dexterity. Generally the job requires 70% sitting, 15% walking, and 15% standing. This job is performed in a generally clean and healthy environment.

Experience

Job related experience within specialized field is required.

Education

High School diploma or equivalent required, college degree preferred.

Certificates & Licenses

Valid driver's license, required auto insurance, and reliable personal transportation.

Certified by Labor and Industries as a self-insured claims administrator or the willingness and ability to obtain certification within a specified period of time.

To be considered for this position, the following documents must be submitted. Incomplete applications will not be screened.

• Online application
• Cover Letter
• Resume
• One professional letter of recommendation
• Transcripts (if applicable)
• Any applicable certification/licensure

NEWESD 101 is an Equal Opportunity Employer and does not discriminate on the basis of sex, race, creed, religion, color, age, national origin, sexual orientation, gender expression or identity, veteran or military status, disability, or the use of a trained guide dog or service animal in its programs or activities and provides equal access to the Boy Scouts and other designated youth groups. NEWESD 101 complies with the Americans with Disabilities Act. Persons who may need some accommodation in the hiring process should contact the human services office. *ADA, Affirmative Action, Title VII, Title IX Officer - Michelle Powers, [redacted]* *504 Officer - Darren Nelson, [redacted]*

You are eligible for SEBB health benefits if NEWESD 101 anticipates you will work at least 630 hours per school year (September 1 through August 31). Your SEBB benefits include:

• Medical insurance - Medical insurance is optional. Employees who carry medical insurance will have a monthly out-of-pocket cost. Employees have the option to cover their family/dependents on medical insurance.
• Dental insurance - Dental insurance is mandatory and free to the employee and their family/dependents.
• Vision insurance - Vision insurance is mandatory and free to the employee and their family/dependents.
• Life and accidental death and dismemberment insurance - Basic life insurance is mandatory, and a $35,000 policy is free to the employee. The employee has the option to purchase additional life insurance.
• Long-term disability insurance - Basic long-term disability insurance is mandatory and is free to the employee. The employee has the option to purchase additional long-term disability insurance.

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Employees have the option to enroll in a flexible spending account.

Participation in School Employees Retirement System is mandatory if your position is eligible. Your position is eligible if:

• the position ever requires at least 70 hours of compensated employment in a month, and
• the position requires at least five months of 70 or more hours of compensated employment per month during a 12-month period, and
• the position is expected to require at least five months of at least 70 hours for two consecutive years.

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Employees may also contribute to a deferred compensation account (457 plan) or a tax-sheltered annuity (403(b) plan).

NEWESD 101 offers the following additional benefits. Some benefits may be prorated based on the employee's work schedule:

• Sick leave
• Vacation leave (not applicable to positions that do not work year-around)
• Bereavement and critical illness leave
• Jury duty leave
• Military leave
• Parental leave
• Emergency leave
• Paid holidays, including one personal holiday per year