Workers' Compensation Claims Representative

City of Sacramento; Sacramento (CA); Hybrid; USD 70,000 - 95,000; Full time

Job summary

City of Sacramento seeks a Workers' Compensation Claims Representative to manage the full claims lifecycle under California law. The role requires coordination with employees, departments, medical providers, and legal entities to ensure timely benefits and return-to-work solutions.

Ideal candidates will have three years of workers' compensation experience, an associate degree or equivalent, and relevant certification.

Qualifications

• Three years of Workers' Compensation claims adjusting experience.
• Associate degree or 60 semester units from an accredited college or university.
• Certification: Experienced Claims Examiner or equivalent required by appointment and licensing regulations.

Responsibilities

• Review accident/injury reports and medical forms to determine actions under CA Workers' Compensation laws.
• Establish and maintain monetary reserves for medical and related costs; prepare settlements when appropriate.
• Process and pay benefits, review medical bills, and defend claims when needed.
• Coordinate return-to-work and communication among injured employees, departments, and providers.
• Attend settlement conferences, hearings, and related meetings; provide exceptional customer service.

Skills

Analytical

Communication

Problem solving

Education

Associate degree or 60 sem. units

Tools

Claims software

MS Office

Job description

THIS JOB POSTING WILL AUTOMATICALLY CLOSE UPON THE RECEIPT OF 150 APPLICATIONS

OR

AT THE FINAL FILING DEADLINE, WHICHEVER OCCURS FIRST.

With supervisor approval, incumbents may be eligible for intermittent remote work; however, they must physically reside within the Sacramento region or have the ability to regularly report to a City of Sacramento physical worksite with little notice.

IDEAL CANDIDATE STATEMENT

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.

Under general supervision, the Workers' Compensation Claims Representative performs a wide variety of responsible duties in claims adjusting related to the City's self-administered Workers' Compensation Program; provides timely Workers' Compensation benefits pursuant to State of California laws; investigates, evaluates, and settles Workers' Compensation claims against the City of Sacramento; attends mandatory settlement conferences, court hearings, and meetings.

DISTINGUISHING CHARACTERISTICS

This exempt classification is populated with multiple incumbents. The Workers' Compensation Claims Representative performs the entire range of specialized duties requiring a thorough knowledge of all aspects of the Workers' Compensation Program. When filled from the outside, significant prior experience in adjusting Workers' Compensation claims is required.

SUPERVISION RECEIVED AND EXERCISED

General supervision is provided by a Workers' Compensation Claims Supervisor or higher-level management staff.

• 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; or, pays death benefits to dependents; reviews and pays related medical bills; reviews and pays expenses incurred to defend the City in contested claims; and 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; settles 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; coordinates benefits with other City benefits; prepares information for submission to the Workers' Compensation Appeals Board, Disability Evaluation Unit, and Administrative Director; files 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.
• Provides exceptional customer service to those contacted in the course of work.
• Other related duties may also be performed; not all duties listed are necessarily performed by each individual holding this classification.

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.

Skill in:

• Evaluate permanent disability.
• Use of computers, computer applications, and software.

Ability to:

• Interpret, explain, and apply Workers' Compensation laws and administrative rules and regulations.
• Analyze complex data, including medical reports, and make appropriate decisions.
• Make accurate arithmetical computations.
• Speak and write effectively.
• Establish and maintain effective relationships with injured employees and their families, attorneys, and physicians.

EXPERIENCE AND EDUCATION

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.

-AND-

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.

PROOF OF EDUCATION

Should education be used to qualify for this position, then proof of education such as, but not limited to, university/college transcripts and degrees should be submitted with your application and will be required at the time of appointment. Unofficial documents and/or copies are acceptable.

An applicant with a college degree obtained outside the United States must have education records evaluated by a credential's evaluation service. Evaluation of education records will be due at time of appointment.

SPECIAL QUALIFICATIONS

Certification:

Possession of an Experienced Claims Examiner designation is required at time of appointment, per CaliforniaInsurance Code Section 11761.

Possession of, or ability to obtain by time of appointment, required post-designation training, pursuant to is required at time of appointment, per California Insurance Code Section 11761 and California Code of Regulations, Title 10, Sections 2592.02, 2592.03, 2592.04, and 2592.05.

PROOF OF CERTIFICATION

Proof of the required certificate and/or license should be submitted with your application and will be required at the time of appointment. Unofficial documents and/or copies are acceptable.