Occ. Code 6818000

ASSISTANT WORKERS COMPENSATION EXAMINER, GRADE 9	6818000
WORKERS COMPENSATION EXAMINER, GRADE 14	6818200
SENIOR WORKERS COMPENSATION EXAMINER, GRADE 18	6818300
ASSOCIATE WORKERS COMPENSATION EXAMINER, GRADE 23	6818400
PRINCIPAL WORKERS COMPENSATION EXAMINER, GRADE 25	6818500

New York State Department of Civil Service

Classification Standard

BRIEF DESCRIPTION OF CLASS SERIES

Workers Compensation Examiners (WCEs) receive and process injured workers claims for benefits under the Workers Compensation Benefits, Disability Benefits, Volunteer Firefighters Benefits, Volunteer Ambulance Workers Benefits, and Volunteer Civil Defense Workers Benefits Laws and related rules and regulations.  They analyze employers reports of injury, medical reports from physicians and health care providers, calculate benefits due, manage claimants cases and prepare information for adjudication.  WCEs may also monitor compliance by employers, medical practitioners, insurance carriers and other parties of interest.  Workers Compensation Examiners exist only at the Workers Compensation Board.

DISTINGUISHING CHARACTERISTICS

          ASSISTANT WORKERS COMPENSATION EXAMINER: entry level; support claims processing, adjudication, and monitoring of compliance by parties of interest.

          WORKERS COMPENSATION EXAMINER:  full performance level; in a claims work group or as a supervisor in a district operation or a compliance program, supports the adjudication of claims or ensures that parties of interest adhere to regulations.  

          SENIOR WORKERS COMPENSATION EXAMINER:  mentors and tutors claims work groups generally comprised of an Associate WCE, a Senior WCE, and a contingent of WCEs, Assistant WCEs and support staff.  Supervises, trains and coaches claims or compliance staff and handles a personal workload of complex cases or issues.

          ASSOCIATE WORKERS COMPENSATION EXAMINER:    In addition to the claims, compliance and quality assurance duties performed by Senior Workers Compensation Examiner, supervises and evaluates staff in compliance and work group members in claims resolution.

          PRINCIPAL WORKERS COMPENSATION EXAMINER:  oversees a number of units, performs the duties typical at the Senior and Associate levels, and in addition, may function as a program manager assuming responsibility for specific claims or compliance functions.

ILLUSTRATIVE DUTIES

ASSISTANT WORKERS COMPENSATION EXAMINER  

Determines, based on established criteria, whether an accident or injury sustained by an employee warrants the indexing of a claims file; enters new case information into electronic files, prepares incoming documents and forms for scanning, schedules hearings, operates courtroom digital audio recording system, verifies employer coverage, cancels and combines duplicate cases, interacts with claimants, employers, insurance carriers and/or attorneys to answer routine questions and to clarify processes or procedures.  They may also have supervisory responsibilities over support staff.

• Receives requests for information from agency staff, claimants, employers, insurance carriers, medical practitioners, attorneys and other parties of interest, and responds to such requests, ensuring that no confidential information is given.

• Receives claims related documents and forms, prepares them for scanning, establishes claims case folders, assigns a case number or forwards the information to no claims or pending file and schedules cases for hearings.

•  Determines eligibility for disability benefits and periods of payment, calculates rates of total disability payments due to claimant based on specific criteria, and submits to appropriate agency for payment.

Evaluates forms and related documents regarding employers compliance with required insurance, reviews forms on medical treatments for claimants and claims for direct payments and, using established guidelines, processes them for payment or refers them to a supervisor.

• Ensures digital audio recording (DAR) system is operating properly, conducts recording tests, verifies that connections with remote locations are working, checks recorder screen for correct screen information, and completes and submits the DAR daily report. 

• As required, oversees support staff.

WORKERS COMPENSATION EXAMINER

Prepares proposed administrative decisions regarding a claim, reviews requests for appeal of a decision, reopens inactive or closed claims to resolve new issues, requests meetings or hearings, ensures that a claims case is ready for the judges (Compensation Claims Referee) or supervisors review, and ensures employers have workers compensation or disability benefits coverage for their employees.  WCEs may also oversee staff located at customer service centers, and those who schedule hearings, handle document intake and regular mail, and index claims cases.

· Reviews claims case file to determine if required forms and documents have been received; requests missing information from appropriate party; prepares claims file, and if applicable according to specified criteria, prepares administrative decision for judges approval or prepares the file for presentation to supervisor or judge for action; prepares hearing notices identifying specific law, rule, regulation or policy to be addressed.

· Processes judges decisions and explains decisions to claimants, responds to questions and provides information on appeal procedures to claimants, employers, insurance carriers and attorneys, and reviews requests for appeal or reopening of a closed case to resolve new issues. 

· Manually calculates Average Weekly Wage (AWW) and resulting awards.

• Reviews documentation of employer insurance coverage and determines penalty and issues notification.

· Provides claimant and employer information to the Boards Office of the Secretary, Fraud Unit, Enforcement Unit, and the Office of the Advocate for Small Businesses and the Office of the Advocate for the Injured Workers.

· Works with Board staff and program personnel on special projects as directed.

SENIOR WORKERS COMPENSATION EXAMINER

Serves as mentor, trains staff on procedures, policies, rules or regulations based on review or audit, assists in reviewing and routing assignments, handles problematic or unusual cases having complex legal issues, and reviews requests for appeals.  They may also function in other program areas of the Board where their role is to ensure that injured workers, employers and parties of interest comply with the law, rules and regulations of the Workers Compensation Board and that Board staff are provided with the tools they need to perform their duties.  Depending on the assignment, Senior WCEs may also perform full supervisory duties.

• Provides staff with instruction on new procedures, policies, precedent cases and special instructions; coaches staff in reaching successful resolution of cases and ensures work performed conforms to policies and procedures; uses performance measures and claims information systems to monitor and address productivity.

• Performs research on questions of statutory and case law as they relate to a specific claim or issue; reviews, routes or responds to work group correspondence;  personally handles a caseload of complex or unusual cases and reviews administrative decisions submitted to, or returned by judges and evaluates medical reports regarding disability benefit cases and authorizes payments.

• Reviews and processes requests for lump sum settlements and Section 32 agreements (an agreement by the claimant and employer settling upon benefits due), which are conclusive, final and binding on all parties.

• Reviews requests for appeals and administrative reopening of inactive or closed claims; reviews, prioritizes and prepares cases under appeal for proposed memoranda; reviews and applies applicable statutes, rules and regulations in the drafting of memoranda and revised decisions.

• Ensures parties comply with laws, rules and regulations; evaluates employers requests for self-insurance status by verifying bonds, letters of credit, etc., requesting actuarial computations and preparing reports and recommendations; audits medical bills for payment using medical fee schedule; evaluates applications made by physicians to provide care and treatment to claimants and maintains Independent Medical Exam (IME) provider records, and oversees searches for closed files and information on external programs such as health insurance data matches, social security and veterans benefits.

• Assists program and administrative staffs by providing information to resolve issues, revise forms, explain procedures and train staff; or educates claimants regarding the Workers Compensation and Disability Benefits systems and their rights and responsibilities.

ASSOCIATE WORKERS COMPENSATION EXAMINER

Serves as team leader, coordinates workflow, monitors quality of work/product, ensures that group members are trained and work is consistent with rules, regulations and policies; communicates with claimants and other parties of interest and informs Program Managers of specific cases or issues as necessary.  They may personally analyze cases or regulatory issues of a complex nature, and after review, may propose appropriate solutions for cases that have been appealed, or regulatory/compliance matters involving multiple issues, and work with judges and conciliators (Senior Attorneys), to assist in bringing cases to resolution or may be assigned special duties, studies or projects when management requires a technical review or opinion.

• Performs supervisory duties such as assigning work, tracking production levels, ensuring that performance measures such as timeliness, accuracy and quality are met, evaluating staff and preparing probationary reports and performance evaluations, counseling and disciplining employees, scheduling and approving use of leave accruals, justifying filling of vacant positions, interviewing candidates, and preparing recommendations for hire.

• Functions as technical expert in claims processing and procedures and works with continuous improvement staff to develop and update procedures, practices and policies for publication on the agencys on-line technical and administrative manual.

• Analyzes claims on appeal to the Board and drafts proposed decisions for Board panel review.

• Maintains a caseload of difficult, multiple-issue disability benefit claims and prepares appeals on special fund disability claims for judges decisions.

• Monitors the performance of licensed representatives, third-party administrators, self-insured employers and groups by investigating and evaluating complaints, participating in field audits and making recommendations.

• Represents program manager and supervisor at executive meetings at the district and executive office levels, communicates with external constituents, and may participate in special committees.

PRINCIPAL WORKERS COMPENSATION EXAMINER

May supervise and manage the activities of one or more local or statewide units, statewide consisting of claims examiners and clerical support staff assigned to the Operations, Compliance or Disability Benefits Bureaus; personally handles very sensitive claims or compliance cases or those involving highly complex situations, assist bureau heads in their assigned program areas with day-to-day activities and special projects.  As the highest level in the Examiner series, Principal WCEs serve as technical experts, advise executive management, offer opinions on legislation, and act as hearing officer in specific disability benefits cases.

• Reviews performance measure reports for statewide claims and compliance operations, identifies productivity and quality issues, and takes and/or recommends corrective action by staff training, deployment, counseling, workload redistribution, etc.

• Ensures that program managers and employees are aware of interpretations of law, court and Board decisions, and changes in procedures, policies, rules and regulations by developing written communications for internal electronic publication, and develops and designs training materials, workshops, seminars and orientations for internal and external customers.

• Advises executive management and district program managers, including administrative and information resource management personnel, internal consultants, and external constituents.

• Supervises and manages new projects, pilot programs, experimental procedures, and/or new processing technologies by performing applicable research, preparing descriptive documentation including recommendation, scope of project or program, drafting procedures and instructions, reviewing schedules and monitoring project or program, making adjustments as necessary, and preparing interim and final reports.

• Attends meetings and speaking engagements regarding specific agency programs or new efforts, drafts speeches for executive or program managers, coordinates and conducts education outreach to constituents regarding policy, law, rules and regulations, responds to complex constituent inquiries, and communicates with the public, elected officials, claimants, attorneys, employers, and insurance carriers.

• Issues administrative determinations and acts as hearing officer within the Disability Benefits Bureau as required.

• Reviews applications for new self-insured individuals and groups, reviews security deposit requirements, ensures security is received, and that all fiscal and programmatic issues are fully implemented.

• Develops and maintains information on health care organizations and works with providers and other State agencies to develop and maintain health care provider networks to ensure that the authorized physicians register is maintained.

MINIMUM QUALIFICATIONS

ASSISTANT WORKERS COMPENSATION EXAMINER

Promotion:  one year of permanent service in a position allocated to Grade 4 or higher.

Open-Competitive:  four years of office experience, one year of which must have been in processing claims, examining claims or adjusting claims or providing customer service in a medical or insurance-based setting.  A high school diploma may substitute for three years of general office experience.

WORKERS COMPENSATION EXAMINER

Promotion:  one year of permanent competitive or non-competitive service in a position allocated to Grade 9 or higher.

Open-Competitive: 

four years of experience examining, investigating or adjusting compensation, accident, liability or health insurance claims. A bachelors degree may substitute for three years of this experience. An associates degree may substitute for two years of this experience. 

SENIOR WORKERS COMPENSATION EXAMINER

Promotion:  one year of permanent service as a Workers Compensation Examiner.

ASSOCIATE WORKERS COMPENSATION EXAMINER

Promotion: one year of permanent service as a Senior Workers Compensation Examiner.

PRINCIPAL WORKERS COMPENSATION EXAMINER

Promotion:  one year of permanent service as an Associate Workers Compensation Examiner.

Rev: 11/17 

NOTE:  Classification Standards illustrate the nature, extent and scope of duties and responsibilities of the classes they describe.  Standards cannot and do not include all of the work that might be appropriately performed by a class.  The minimum qualifications above are those which were required for appointment at the time the classification Standard was written.  Please contact the Division of Staffing Services for current information on minimum qualification requirements for appointment or examination.