Workers' Compensation Claims Representative

About the role

The ideal candidate will be resourceful, collaborative, and solutions-oriented with experience managing complex workers’ compensation claims. Experience working with first responder populations, including police and fire personnel, is highly desirable, but not required, along with an understanding of the unique medical, operational, and return-to-work considerations associated with these roles. The ideal candidate will take a proactive and solutions-focused approach to workers’ compensation, thinking beyond traditional workers’ compensation practices to address treatment barriers and support timely recovery and return to work. They will communicate effectively with injured employees, medical providers, departmental partners, and maintain a strong commitment to high-quality service, integrity, and proactive case management.

Responsibilities

• Reviews accident and injury reports and Doctor's First Report of Injury forms to determine proper actions under Workers' Compensation laws and regulations;
• Obtains background information; and opens and adjusts claims;
• Pays temporary disability, permanent disability, and life pension benefits to injured employees;
• Pays death benefits to dependents;
• Reviews and pays related medical bills;
• Pays expenses incurred to defend the City in contested claims;
• Verifies mileage payment requests, pharmacy reimbursements, and other bills;
• Establishes and maintains monetary case reserves to cover medical costs and projected miscellaneous and compensation costs;
• Prepares written requests for settlements;
• Setstlements litigated cases that do not require a defense attorney and advises as appropriate;
• Reviews cases for subrogation potential and files related actions;
• Computes permanent disability case ratings and awards;
• Congnolates benefits with other City benefits;
• Prepares information for submission to the Workers' Compensation Appeals Board, Disability Evaluation Unit, and Administrative Director;
• Filles appropriate actions such as answers, declarations, pleadings and objections;
• Communicates verbally and in writing with injured employees, their departments, physicians, dependents, attorneys, City safety representatives, Workers' Compensation Appeals Board members, and other interested parties;
• Reviews established claims periodically to prompt action and closure, and/or settlement;
• Sets medical evaluations and coordinates return to work, interactive process, utilization review, independent medical review, and independent bill review;
• Attends mandatory settlement conferences, hearings, and meetings relevant to cases.

Requirements

Experience: Three years of Workers' Compensation claims adjusting experience in an insurance company, third-party administrator, or self-insured employer. Public agency experience is desirable.

Education: Possession of an Associate's Degree or 60 semester units or equivalent quarter hours from an accredited college or university with major course work in public or business administration, economics, accounting, human resources, or a related field. Substitution additional qualifying experience may substitute for the required education on a year for year basis. Or - Possession of certificate proving successful completion of the Self-Insurance Administrator's Examination may substitute for the required education.

Qualifications

• Knowledge of: State of California Workers' Compensation laws, administrative regulations, and claims adjusting procedures.
• Principles and practices of permanent disability rating, utilization review program, independent medical review program, independent bill review program, supplemental job displacement benefits program, return to work program and disability management programs.
• Principles and practices of reserving and excess carrier reporting.
• Medical and legal terminology relating to Workers' Compensation matters.
• Oral presentation techniques.

Skills

Ability to: Interpret, explain, and apply Workers' Compensation laws and administrative rules and regulations.

Ability to: Analyze complex data, including medical reports, and make appropriate decisions.

Ability to: Make accurate arithmetical computations.

Ability to: Speak and write effectively.

Ability to: Establish and maintain effective relationships with injured employees and their families, attorneys, and physicians.

Benefits

Proof of certification and/or license should be submitted online with your application. Proof of certification and/or license will be required at time of appointment.

Pay

The City of Sacramento offers bilingual pay for bilingual employees.

Schedule

The City of Sacramento adheres to the California Public Employees' Retirement System (PERS) and the California Public Employee's Pension Reform Act (PEPRA).