Sr. Workers Compensation Claims Examiner

Website Special Districts Association of Oregon


The Sr. Workers’ Compensation Claims Examiner is responsible for analyzing more complex workers compensation claims inclusive of investigation and determination of benefits due

Essential Functions/Major Assignments

· Manages a caseload consisting of a wide variety of workers’ compensation claims and makes timely and accurate compensability decisions in accordance with the Oregon Statutes and Administrative Rules and maintains 90% compliance standard

· Analyzes and processes complex or technically difficult workers’ compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution

· Conduct thorough and complete investigations involving compensability, coverage and third-party liability;

investigations may include interviews with involved parties and consultations with medical professionals

· Evaluate claim exposure and set appropriate reserves; document all reserve activity in the claim notes

· Aggressively manage medical treatment and pursue early return to work; refer for Independent Medical Examinations as appropriate

· Provide superior customer service to all member district personnel, Board/Trust members, management and co-workers

· Manage and control the strategy and direction of all claims through development of a claim strategy plan; the claim strategy plan should be updated with any change in the fact pattern of the claim

· Evaluate and negotiate claim settlements within authority limits

· Regularly communicate with member district management throughout the life of the claim to provide status updates of the claim and provide assistance to the membership with how to manage the employee’s absence, return to work etc.

· Oversee and analyze expenses within the framework of cost containment and the associated risks of an adverse order. Communicate these issues with member district management/employers throughout the life of the claim

· Issue all payments and state filings accurately and timely

· Manage medical treatment (Examples: review chart notes to determine if treatment is on track/excess, contact doctor for treatment plan and anticipated return-to-work date, refer for Independent Medical Evaluation, etc.) and pursue early return to work in coordination with the Return to Work Consultant

· Obtain records as needed to process claims; including but not limited to prior/current medical records, police reports, etc.

· Assign to outside vendors as necessary (Example: Surveillance, Nurse Case Management, Managed Care Organization)

· Review and approve bills in a timely and appropriate manner (Example: Medical treatment bills, MCO bills, IME bills, surveillance bills etc.).

· Manage claim litigation by working closely with defense counsel to develop a strategic defense within an outlined budget

· Attend mediations and hearings

· Report claims to excess carrier at reporting threshold; respond to requests for information in a timely and professional manner

· Request refunds from state programs

· Pursue third party recovery as appropriate

· Take a leadership role within the department by mentoring and assisting less experience Workers’ Compensation Claims Examiners

· Provide trainings to clients as requested

· Participate in claim reviews, board meetings, trainings

· Ensure that files are closed properly and timely

Specific Job Knowledge, Skill and Ability

· Ability to obtain sufficient training to acquire or maintain Claims Examiner certification and compliance with the rules and statutes of the state jurisdiction at 90%

· Must be able to work independently with minimal supervision

· Must be able to be decisive in the application and determination of claims and settlement agreements

· Must be able to collaborate effectively with members of the Workers’ Compensation team; strive to meet the needs of the client while building internal relationships; support new efforts and approaches; foster an environment of continuous improvements

· Exceptional planning and organizing skills with attention to detail

· Must possess exceptional communication skills; both verbally and in writing

· Ability to analyze complex medical and legal information

· Superior critical thinking skills

· Outstanding customer service skills

· Ability to manage multiple priorities and objectives

· Must be able to easily adapt to change

· Must have the ability to listen and understand client needs and anticipate obstacles to client satisfaction; ability to represent client’s needs internally

· Must be willing and able to travel in course of duties within the state of Oregon

· Must be able to maintain confidentiality of sensitive information

Education, Experience, and Certification/Licensure:

Required Qualifications

· High school diploma or equivalent

· Minimum of seven years of progressively responsible workers’ compensation claims management experience

· Current Oregon claims examiner certification required


· An equivalent combination of education, training and experience sufficient to successfully perform the essential duties of the job

Desired Qualifications

· Bachelor’s degree in related field preferred

To apply for this job email your details to

Platinum Sponsors