Adjudicator

**Job Summary (external)**:
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Adjudicators play a pivotal role in the claims process, often serving as the initial point of contact for workers and employers during sensitive circumstances. They are tasked with creating a positive first impression by acknowledging reported injuries and gathering pertinent information necessary to make timely and well-communicated decisions. Through telephone and written correspondence, Adjudicators determine eligibility for compensation benefits and services, ensuring decisions are consistent with established policies and legislation.

We are seeking service-oriented, proactive, and results-driven professionals capable of thriving in a fast-paced environment. Utilizing a proactive claims management approach, Adjudicators make and communicate eligibility decisions promptly and consistently. They provide essential information to internal and external stakeholders regarding recovery and return-to-work processes, addressing the needs of workers and employers by actively listening, collecting and conveying relevant information, and clarifying rights, responsibilities, and obligations.

**Job Duties**:
Determines which claims are acceptable and authorizes/denies entitlement to compensation on an ongoing basis; communicates the decision and rationale to injured workers, employers, representatives, and healthcare practitioners.

Gathers, assembles, reviews, develops, and assesses information and opinions through written correspondence, in-person meetings, and telephone to establish initial and ongoing entitlement to compensation.

Communicates with injured workers, employers, representatives, healthcare practitioners, witnesses, and other involved parties to obtain/provide information, respond to enquiries and explain decisions, in writing or verbally.

Gathers appropriate wage information and provides direction to Payment Assessors re: payment of a claim and duration.

Identifies claims where a pre-existing condition exists, establishes entitlement accordingly, and authorizes or denies cost relief to employers.

Manages and facilitates the overall claim process (ie. assessing, planning, implementing, coordinating, monitoring, evaluating and terminating) including Time Loss claims up to 8 weeks duration; Medical Treatment claims up to 14 weeks; Occupational Disease claims up to 8 weeks and Hearing Loss claims for the duration of the claim.

Acts as a primary contact for injured workers, employers, representatives, healthcare practitioners, and specialized service providers to ensure the coordinated management of claims through the recovery and return to work processes or other resolutions.

Facilities established protocols for potential stress/crisis situations including involvement with the Special Services Unit.

Implements Chiropractic and Physiotherapy Protocol by identifying the appropriate category and coverage period and notifies all parties in writing. Monitors no time loss claims involving physiotherapy or chiropractic treatment for up to 14 weeks from date of injury. Manages noise induced hearing loss claims for the entire duration of the claim.

Adjudicates Fatality claims and determines spousal and dependent’s entitlement on fatality claims and refers files to appropriate internal resources for ongoing management.

Delivers presentations or attends information/discussion sessions on behalf of the WCB with external stakeholders.

Provides service both independently, or in consultation with internal/external service providers, to injured workers by assessing and facilitating return to work on an individual basis. This includes development of a strategy to bring each claim to resolution.

Promotes and supports workplace-based disability management programs.

Initiates recovery of overpayments within guidelines.

Authorizes medical aid expenditures on files up to $25,000 and lump sum benefits related to fatalities up to $75,000 (spousal benefits) and makes recommendations of payments beyond their authorization limit to the Supervisor/Manager/Director.

Identifies claims where cost allocation/relief is appropriate per legislation and policy.

Gathers/assembles information requested, implements decisions and reviews information received from senior staff, the Review Office, Medical Review Panel, and Appeal Panel.

Ensures proper recording of claims involving inter-provincial and third party, as well as coding of all occupational disease claims.

Identifies and recommends improvements in service or system/policy changes related to adjudication and case management.

Performs other related duties as assigned.

**Qualifications**:
Completion of a two (2) year diploma in a related discipline and a minimum three (3) years' experience in a similar environment making entitlement decisions based on a defined set of criteria (ie. policies, procedures, legislation, etc.) including client service, or an equivalent combination of education and/or experience

Proficiency