OPEN COMPETITIVE RECRUITMENT

Open to all qualified candidates. 

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.