Recent Grad - Workers' Compensation Claims Examiner
Under close supervision, the incumbent conducts fact-finding to properly gather, assess, and adjudicate claims of disabling occupational diseases and death arising under the Act. At this level, the incumbent adjudicates certain selected and less difficult claims or adjudicates a variety of increasingly difficult claims as a continuation of their training and development for work in the career ladder progression. Assesses the facts of the claim, determines the proper disposition of claims, and drafts a final decision. Reviews and selects a variety of factual and medical issues within a claim in order to adjudicate and/or manage the claim. Applies knowledge of DCMWC laws, regulations, and policies to assigned cases selected for training and developmental purposes. Works under close supervision when properly identifying and determining the Responsible Operator (RO), which may include simple liability determinations. This involves gathering, reviewing, and analyzing a variety of employment and evidentiary documents, which may have differences of a factual nature, from a variety of sources to make these determinations. Works to resolve common disputes over medical bill responsibility between the claimant and the RO - referring stakeholders to the supervisor or higher-graded specialist to address difficult problems or complex disputes. May assist the supervisor in holding entities accountable for final decisions under the Act. Receives and reviews medical examinations provided by the Department of Labor for completeness and compliance with the Act. Working under close guidance and review of the supervisor, the incumbent properly analyzes and adjudicates factual medical evidence resulting from the medical examination for which there are established precedents; frequently coordinates with providers in gathering or clarifying information; and refers determinations of whether the results support an award or a denial of a claim to the supervisor. In instances that involve medical questions or concerns, the incumbent factually summarizes the questions for reference to a supervisor or to medical experts in various professional fields of study, initiates contact to request clarification of routine and complex medical questions, and gathers additional statements that contribute to recommending final claim decisions. Briefs findings of facts to the physician or supervisor involved. After conducting review and analysis of all applicable evidence and after the expiration of all extensions, the incumbent drafts initial and final decisions for assigned cases subject to close review by the supervisor before issuance. Utilizes knowledge of workers' compensation laws and legislation, case law, and precedents to carefully gather and weigh factual evidence, determines the extent of disability, and ensure recommended decisions comply with established regulations. Works closely with a higher-graded specialist or supervisor in assessing opposing viewpoints and/or medical evidence. Effectively communicates to the claimant the options available and time limits for challenging the decision. Drafted decisions are referred to the supervisor for action based on research into and analysis of pertinent rules, requirements of law, medical standards, court decisions, and policy guidelines. If a decision has been appealed, the incumbent prepares claims for hearing referrals to the Office of the Administrative Law Judge (OALJ) or other appellate body. This preparation is carried out with continual advice and guidance from the supervisor or higher-graded specialist. If errors are identified in the OALJ's Decision & Order (D&O), the incumbent reexamines the claim in a timely manner and works with higher-graded staff, as appropriate, to ensure final decisions align with the evidence. If warranted, the claim is referred to a supervisor and the incumbent works closely with higher-graded staff in determining if a request for reconsideration or additional appeal is warranted and takes all appropriate follow-up actions under the close guidance of the supervisor. Depending on the outcome, the incumbent assists in performing one or more of the following post-appellate actions:
processes modifications and remands; promptly suspends benefits; creates an automated accounts receivable in the accounting subsystem and notifies the claimant of the overpayment; notifies the RO or their counsel to determine if they are in agreement with the award; and issues either ongoing or interim payments from the Trust Fund. For assigned cases, the incumbent determines the amount of monetary compensation payable to the claimant for disability or death and verifies benefit rates and periods of disability. Once entitlement has been established under the Act, the incumbent monitors ongoing claims to ensure appropriate medical treatment is authorized and that benefits are paid properly. Performs other duties as assigned. IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE WILL NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. GS-07:
Applicants must have 52 weeks of specialized experience equivalent to at least the next lower grade level, GS-5 in the Federal Service. Specialized experience is experience that equipped the candidate with the particular knowledge, skills and abilities to successfully perform the duties of the position being filled. Examples of qualifying specialized experience include:
Demonstrating the knowledge and ability to develop, examine, investigate, adjudicate, and/or authorize claims for compensation or benefits; Examining and developing reports of disability/injury and/or death and obtaining documentation; Ability to interpret medical reports and to develop and evaluate pertinent medical facts and evidence from medical reports and diagnostic tests and studies; Applying and interpreting laws, regulations, policies, precedents; Ability to prepare drafts of brief findings of fact and drafts of proposed questions.
Estimated Salary: $20 to $28 per hour based on qualifications.
processes modifications and remands; promptly suspends benefits; creates an automated accounts receivable in the accounting subsystem and notifies the claimant of the overpayment; notifies the RO or their counsel to determine if they are in agreement with the award; and issues either ongoing or interim payments from the Trust Fund. For assigned cases, the incumbent determines the amount of monetary compensation payable to the claimant for disability or death and verifies benefit rates and periods of disability. Once entitlement has been established under the Act, the incumbent monitors ongoing claims to ensure appropriate medical treatment is authorized and that benefits are paid properly. Performs other duties as assigned. IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE WILL NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. GS-07:
Applicants must have 52 weeks of specialized experience equivalent to at least the next lower grade level, GS-5 in the Federal Service. Specialized experience is experience that equipped the candidate with the particular knowledge, skills and abilities to successfully perform the duties of the position being filled. Examples of qualifying specialized experience include:
Demonstrating the knowledge and ability to develop, examine, investigate, adjudicate, and/or authorize claims for compensation or benefits; Examining and developing reports of disability/injury and/or death and obtaining documentation; Ability to interpret medical reports and to develop and evaluate pertinent medical facts and evidence from medical reports and diagnostic tests and studies; Applying and interpreting laws, regulations, policies, precedents; Ability to prepare drafts of brief findings of fact and drafts of proposed questions.
- Department:
0991 Worker's Compensation Claims Examining - Salary Range:
$43,251 to $56,222 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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