workers' Compensation Representative II

OPEN COMPETITIVE RECRUITMENT

Open to all qualified candidates. 

Tentative examination dates for this recruitment:

  Week of TBD - Blind supplemental scoring

  Week of TBD - Oral interview

Dates may change due to unforeseen circumstances. Candidates who pass each phase of the recruitment process will be notified of the official examination dates.

Under direction, to administer assigned claims (Medical Only (MO), Indemnity, Future Medical (FM) and litigated claims) filed against the City's Self-Insured and Self-Administered Workers' Compensation Program; to perform a variety of advanced clerical and basic administrative duties in connection with the administration of the City's Workers' Compensation Program, including, but not limited to New Loss Setup, First Response of Injury (FROI) and Subsequent Response of Injury (SROI), Centers for Medicare and Medicaid Services (CMS), Insurance Services Office (ISO), lost time, and accounts payable (AP) reporting, and check processing; to follow established protocols to ensure that claims are handled in the most effective way while delivering a customer-centric claims service; and perform related work as required.

Responsible for workers' compensation functions requiring technical and specialized knowledge; reviews, examines, investigates, analyzes, and resolves workers' compensation claims; develops strategic action plans to bring claims to a prompt and equitable resolution; identifies key interested parties and obtains recorded statements as necessary; assesses witnesses' credibility; analyzes and resolves conflicts in the evidence; determines claim compensability based on witness statements and other evidence; accepts or delays claims and makes recommendations to Workers' Compensation Administrator regarding claim denials; establishes appropriate reserve levels based on estimate of financial exposure and updates reserves upon receipt of new information; accurately determines average weekly wages and workers' compensation benefit rates and pays benefits timely; directs appropriate staff to issue notices; makes payments in accordance with state-mandated requirements; interacts with injured employees to ensure awareness and understanding of the workers' compensation process, requirements, and statutory benefits; assesses subrogation potential and pursues reimbursement; negotiates claim settlements within established limits; presents settlement recommendations to business partners, if required; independently resolves liens without defense attorney involvement; serves as a liaison between medical providers, claimants, legal professionals, and business partners; informs business partners of injured employees' work restrictions and coordinates appropriate limited duty assignments; reviews medical reports to ensure that the appropriate American Medical Association (AMA) guidelines have been applied when rating permanent impairment; communicates with defense attorneys and business partners on litigated cases and develops strategies for a claim resolution; develops litigation strategy with legal counsel; prepares or reviews legal documents for submission to the Workers' Compensation Board; manages all discovery requests by the defense attorney; attends and participates in hearings when requested; audits incoming invoices and/or bills for accuracy and appropriateness; coordinates medical treatment for injured employees and interacts with medical providers regarding employees' medical history and job requirements; processes treatment requests in line with applicable state-mandated Utilization Review standards; coordinates with field investigators when conducting compensability, subrogation or sub- rosa investigations; prepares claim status reports and presents to business partners; complies with excess insurance reporting requirements and seeks reimbursement where appropriate; seeks reimbursement from co-defendants or subsequent injury funds; identifies and reports all suspected fraudulent activity to the appropriate authorities and/or state agencies; complies with Medicare Set Aside (MSA) obligations; stays abreast of applicable laws, new trends, pending legislation, and case law related to workers' compensation; manages outgoing payments in a timely manner; effectively manages business partners and other communications and maintains claim notes and status; assists medical providers, vendors, and supervisors with questions and inquiries in order to provide proper care and treatment for injured employees; contacts and/or advises injured workers regarding procedures and regulations; reviews all incoming reports of injury; reviews all files open for over one year for potential closure; may assist in coordinating light duty assignments; investigates compensability and subrogation issues; reviews and processes benefit payments and other documents for accuracy; authorizes appropriate payments within pre-established limits; prepares and maintains accurate reports and records, both manually and electronically; supervises personnel engaged in maintenance of complex record keeping system; adheres to California Labor Code, regulatory requirements, and Memorandums of Understanding; performs other related duties as assigned.

Employment Standards: 

Knowledge of workers' compensation law, regulations, case law, labor code, claims management, disability rating systems, and medical terminology; employee care policies and procedures; technical areas such as award calculations, permanent disability (PD) rating, structured settlements, catastrophic claims management, MSA, identification of complex medical conditions; knowledge and application of AMA Guides; modern office methods, procedures and equipment, including filing systems; workers' compensation statutory time frames and benefits, statutory form filing requirements, and claims handling and payment techniques; City procedures; payroll and budget procedures; basic arithmetic and accounting; spelling, grammar, and punctuation.

Skill in time management and organizational skills; providing excellent customer service; effective analytical and interpretive skills; conducting thorough investigations; effectively managing business partners; operating modern computers and related software; computing benefits in a timely and accurate manner.

Ability to prioritize and juggle multiple tasks simultaneously; effectively negotiate settlements; estimate medical reserves based on treatment history and life expectancy; estimating indemnity benefits based on life expectancy; establish and maintain accurate monetary reserves; communicate effectively, both orally and in writing; maintain strict confidentiality regarding employee, business partner, and vendor information; exercise sound judgment and critical thinking; conduct thorough investigations; establish and maintain effective working relationships with supervisors, fellow employees, and the public; deal effectively with medical, legal, and other professionals; understand and apply a wide variety of legal requirements, technical procedures, and policies; understand medical terminology; develop and organize records and reports; understand and explain a wide variety of technical procedures and policies; work independently and exercise judgment and initiative in performing assigned duties.

Education/Training: Graduation from high school or equivalent, five years of increasingly responsible clerical work, and two years of workers' compensation claims experience, including at least one year of experience handling California Labor Code §4850 claims.

License & Certificates:  A valid California Self-Insurance Administrator's Certificate at time of appointment and obtain a minimum of 20 hours post-designation workers' compensation training every two years as required by the State of California. All required licenses and certificates must be maintained throughout employment in this classification.

A valid California Class "C" Driver's License or equivalent may be required at time of appointment.