Nature of Work
Under general supervision, reviews, evaluates, and processes an assigned caseload of Workers Compensation claims. Responsible for a caseload involving lost time claims with less than one hundred and four weeks of indemnity benefits. Caseload will include hearing loss, and occupational disease (e.g., repetitive motion, carpal tunnel, chemical exposure, dermatitis, etc.) and claims requiring surgery. Performs related duties as required.

Distinguishing Characteristics
The Claims Representative 2 is distinguished from the Claims Representative 1 by the responsibility of claims assigned. Claims Representative 2 is responsible for a caseload involving lost time claims with less than one hundred and four weeks of indemnity benefits. Caseload includes hearing loss, and occupational disease (e. g., repetitive motion, carpal tunnel, chemical exposure, dermatitis, etc.) and claims requiring surgery.

Examples of Work
Analyzes assigned new claims and reopening applications; determines applicability of coverage and chargeability.
Contacts claimants, employers, physicians, witnesses, and others to gather and verify information; secures salary information and determines compensation rate.
Determines claim compensability.
Identifies claims needing vocational rehabilitation for referral to rehabilitation specialists and monitors progress of rehabilitation services rendered within assigned authority.
Identifies subrogation opportunities; initiates recovery procedures.
Requests treatment plans from physicians and other clinical providers; reviews and develops a case management plan under general supervision.
Reviews requests for treatment, diagnostic studies, change of physicians, surgery, payment of medical expenses and payment of indemnity benefits.
Evaluates hearing loss claims and determines employer allocation/chargeability; evaluates audiograms and determines impairment rating based on current accepted guidelines.
Consults with medical management nurse on complex medical issues.
Requests independent medical examinations; reviews treatment plans in relation to established treatment guidelines.
Explains basis for and results of decisions and appeal rights to physicians, attorneys, government officials, other clinical providers and other interested parties.
Reviews requests for settlement to determine that related payments are made in accordance with agency policies and procedures.
Works with injured worker, physician and employer to identify return to work opportunities through modified alternate job duties or trial return to work.
Assists attorneys in litigated claims.

Knowledge, Skills and Abilities
Knowledge of West Virginia Workers Compensation statute, rules, regulations, policies and procedures.
Knowledge of West Virginia court precedent setting decisions and application of rulings.
Knowledge of claim management principles and techniques.
Knowledge of medical terminology, anatomy, body systems, treatment protocol, surgical procedures and their complications, and the etiology of occupational diseases.
Ability to communicate effectively, both orally and in writing.
Ability to interpret various forms of technical information and make appropriate decisions.
Ability to establish and maintain effective working relationships with the public, providers and other employees.
Ability to operate a personal computer, recording equipment and other office equipment.

Minimum Qualifications      [Top]
Training:
Graduation from a standard four-year high school or the equivalent.
Experience:
Three years of full-time or equivalent part-time paid experience in the investigation, evaluation, and settlement of workers compensation claims with an insurance company, self-insured or third party administrator; OR four years of full-time or equivalent part-time paid experience working with insurance claims or in claims/insurance adjusting, claims investigation, paramedic or medical assistant field.

Substitution:
Course work from an accredited four-year college or university, or related business school or vocational training may substitute through an established formula on a year-for-year basis for the experience OR Successful completion of the AIC course of study through the Insurance Institute of America, certification as a Certified Case Manager (CCM) or Certified Insurance Rehabilitation Specialist (CIRS) may substitute for one year of the required experience.

Established: 3/21/96
Effective:     4/01/96