Workers' Compensation Compliance Series

California State Personnel Board Specification

Series established April 24, 1990

Scope

This series specification describes four professional classes to be used in performing, supervising and managing activities of the Audit and Enforcement Unit of the Department of Industrial Relations' Office of Benefit Assistance and Enforcement.

Definition of Series

Workers' Compensation Compliance Officers have considerable knowledge in workers' compensation audits procedures and the application and interpretation of program policies, procedures, rules, regulations, and appropriate laws. Workers' Compensation Compliance Officers independently conduct audits of the most complex cases of insurers, self-insured employers, and third-party administrators. Workers' Compensation Compliance Officers assure prompt receipt of full benefits to injured workers by identifying compensation due injured workers, reporting on problems and deficiencies, and taking effective action. The Supervising Workers' Compensation Compliance Officer plans, organizes, and directs the work of a staff of Workers' Compensation Compliance Officers and Senior Workers' Compensation Compliance Officers in a designated area of the State. The Workers' Compensation Compliance Manager is responsible for planning, organizing, and managing the operations of the Unit on a statewide basis.

Entry Levels

Entry into this series is typically from the Workers' Compensation Assistant class or outside experience comparable to duties which have provided knowledge in the workers' compensations laws, rules, regulations, and policies.

Factors Affecting Position Allocation

Degree of supervisory responsibility, area of geographic concern, scope and consequence of decisions made, sensitivity and complexity of work assignments, and program and policy involvement serve as differentiating factors between individual classes.

Definition of Levels

Workers' Compensation Compliance Officer

This is the full journey level class in the series. Under general direction of a Supervising Workers' Compensation Compliance Officer in the Audit and Enforcement Unit, conducts audits of insurers, self-insured employers, and third-party administrators to assure that they are fulfilling their obligations and responsibilities under the workers' compensation law and regulations and that injured workers are receiving their full benefits promptly; as appropriate, identifies compensation due injured workers and reports on problems and deficiencies, issues notices of assessment, determines administrative penalties, and issues notices of penalty assessments; explains audit findings; prepares reports; represents the Department, makes presentations, and testifies at conferences, hearings, and judicial proceedings; may act as leadperson and assist in training of subordinate staff; and does other related work.

Senior Workers' Compensation Compliance Officer

This is the advanced journey level and specialist class in the series. In addition to the above, incumbents in this class must exercise independence and�proficiency in conducting audits of the most complex cases, typically involving large insurance companies; hold appeal hearings on administrative penalties issued by Workers' Compensation Compliance Officers and issue written determinations including a statement of the basis for their decision; and, as directed, conduct special projects and assignments related to workers' compensation compliance.

Supervising Workers' Compensation Compliance Officer

This is the supervisory level in the series. Under general direction of the Workers' Compensation Compliance Manager, plans, organizes, and directs the work of subordinate staff in a major geographical area; provides training, evaluates performance, and recommends appropriate action; assists the staff with unusual or difficult cases; confers with the unit manager to assure uniform application and interpretation of program policies and procedures; attends meetings and conferences to give advice and information on workers' compensation programs and policies; and does other related work.

Workers' Compensation Compliance Manager

Under general direction, plans, organizes, establishes policies for, and directs the work of the staff of the Audit and Enforcement Unit; assures that�the unit operates at optimum efficiency; serves as expert consultant on workers' compensation audits; selects, trains, and evaluates the performance of unit personnel; takes or recommends appropriate personnel actions; maintains uniformity in the application of unit policy, procedures, rules, regulations, and appropriate laws; gives speeches, writes articles, and conducts courses in workers' compensation law; analyzes pending legislation and participates in recommending future legislation; works with top management of the Division and Department in the formulation of overall policy regarding workers' compensation and departmental operations; and does other related work.

Minimum Qualifications

Workers' Compensation Compliance Officer

Either I

One year of experience in California state service performing the duties of a Workers' Compensation Assistant, Range C. (Those with six months' experience may take the examination but may not be appointed until the completion of 12 months of experience.)

Or II

Experience: Three years of experience which must have been acquired in one or a combination of the following types of disability insurance experience:

1. Reviewing, investigating, auditing or adjusting workers' compensation claims in a nonclerical capacity and with direct client applicant contact or a workers' compensation carrier, public agency or self-insured employer or such employer's adjusting agent. (Experience in California state service applied toward this requirement must have included performing duties of a class comparable in level to Workers' Compensation Assistant, Range C, or Workers' Compensation Insurance Representative II for at least one year.)

2. Performing claims examination work of workers' compensation insurance carriers and with responsibility for reviewing the work of others. (Experience in California state service applied toward this requirement must have been performing duties of a class comparable in level to Insurance Examiner, Range

E. )

3. Conducting audits of workers' compensation claim files for insurers to determine compliance with the Labor Code.

4. Reviewing workers' compensation cases to determine legal issues and potential settlement values and appearing as representative for an insurance carrier, employer or claimant before the Workers' Compensation Appeals Board with authority to settle the cases at hearing. and

Education: Equivalent to graduation from college, preferably with emphasis in�Insurance, Economics or Business Administration. (Additional qualifying experience may be substituted for the required education on a year-for-year basis.)

Senior Workers' Compensation Compliance Officer

Either I

One year of experience in California state service performing the duties of a Workers' Compensation Compliance Officer, Workers' Compensation Consultant or Workers' Compensation Rehabilitation Consultant.

Or II

Four years of experience which must have been acquired in one or a combination of the following types of professional disability insurance experience:

1. Reviewing, investigating, auditing or adjusting workers' compensation claims in a nonclerical capacity and with direct client applicant contact for a workers' compensation carrier, public agency or self-insured employer or such employer's adjusting agent. (Experience in California state service applied toward this requirement must have included performing duties of a class comparable in level to Workers' Compensation Assistant, Range C, or Workers' Compensation Insurance Representative II for at least two years.)

2. Performing claims examination work of workers' compensation insurance carriers and with responsibility for reviewing the work of others. (Experience in California state service applied toward this requirement must have been performing duties of a class comparable in level to Insurance Examiner, Range

E. )

3. Conducting audits of workers' compensation claim files for insurers to determine compliance with the Labor Code.

4. Reviewing workers' compensation cases to determine legal issues and potential settlement values and appearing as a representative for an insurance carrier, employer or claimant before the Workers' Compensation Appeals Board with authority to settle cases at hearing. and

Education: Equivalent to graduation from college, preferably with emphasis in�Insurance, Economics or Business Administration. (Additional qualifying experience may be substituted for the required education on a year-for-year basis.)

Supervising Workers' Compensation Compliance Officer

Either I

One year of experience in California state service performing the duties of a Senior Workers' Compensation Compliance Officer or two years of experience performing the duties of a Workers' Compensation Compliance Officer, Workers' Compensation Consultant, or Workers' Compensation Rehabilitation Consultant.

Or II

Experience: Five years of experience which must have been acquired in one or�a combination of the following types of professional disability insurance experience, at least one year of which shall have been in a supervising capacity. (Experience in California state service applied toward the supervisory requirement must have been performing the duties of a class comparable in level to Workers' Compensation Insurance Representative III):

1. Reviewing, investigating, auditing or adjusting workers' compensation claims in a nonclerical capacity and with direct client applicant contact for a workers' compensation carrier, public agency or self-insured employer or such employer's adjusting agent. (Experience in California state applied toward this requirement must include performing duties of a�class comparable to the level of Workers' Compensation Insurance Representative III or Workers' Compensation Consultant for at least one year.)

2. Performing claims examination work of workers' compensation insurance carriers and with responsibility for reviewing the work of others. (Experience in California state service applied toward this requirement must have been in performing the duties of a class comparable in level to Insurance Examiner, Range E.)

3. Conducting audits of workers' compensation claim files for insurers to determine compliance with the Labor Code.

4. Reviewing workers' compensation cases to determine legal issues and potential settlement values and appearing as a representative for an insurance carrier, employer, or claimant before the Workers' Compensation Appeals Board with authority to settle cases at hearing. and

Education: Equivalent to graduation from college, preferably with emphasis in�Insurance, Economics or Business Administration. (Additional qualifying experience may be substituted for the required education on a year-for-year basis.)

Workers' Compensation Compliance Manager

Either I

One year of experience in California state service performing the duties of a�Supervising Workers' Compensation Compliance Officer, Supervising Workers' Compensation Consultant, or Area Supervisor, Rehabilitation Bureau, or two years of experience in the Department of Industrial Relations in a comparable level management class that has provided extensive knowledge of the workers' compensation system.

Or II

Experience: Broad and extensive (more than five years) of experience which must have been acquired in one or a combination of the following types of professional disability insurance experience, at least two years of which shall have been in a supervisory or managerial capacity (California state service applied toward the supervisory requirement must have been performing the duties of a class comparable in level to Supervising Workers' Compensation Consultant or Area Supervisor, Rehabilitation Bureau):

1. Reviewing, investigating, auditing or adjusting workers' compensation claims in a nonclerical capacity and with direct client/applicant contact for a workers' compensation carrier, public agency or self-insured employer or such employer's adjusting agent. (Experience in California state service applied toward this requirement must have included performing the duties of a class comparable in level to Workers' Compensation Insurance Representative III or Workers' Compensation Insurance Supervisor II for at least one year.)

2. Performing claims examination work of workers' compensation insurance carriers and with responsibility for reviewing the work of others. (Experience in California state service applied toward this requirement must have included performing the duties of a class comparable in level to Insurance Examiner, Range E.)

3. Conducting audits of workers' compensation claim files for insurers to determine compliance with the Labor Code.

4. Reviewing workers' compensation cases to determine legal issues and potential settlement values and appearing as representative for an insurance carrier, employer or claimants before the Workers' Compensation Appeals Board with authority to settle cases at hearing. and

Education: Equivalent to graduation from college, preferably with emphasis in�Insurance, Economics or Business Administration. (Additional qualifying experience may be substituted for the required education on a year-for-year basis.)

Knowledge and Abilities

Workers' Compensation Compliance Officer

Knowledge of: Principles, practices, and procedures of the California Workers' Compensation System and Appeals Board; provisions of the Labor Code, rules and regulations, leading court decisions and policies relating to workers' compensation court decisions and policies relating to workers' compensation coverage, insurance, enforcement, rights and benefits; rules of practice, interpretation, and application of the schedule of ratings to permanent disabilities; general accounting, auditing, and insurance principles applicable to self-insurance; laws and rules governing temporary disability, death benefits, rehabilitation; medical issues related to workers' compensation claims; internal auditing procedures; automated programs utilized in insurance claim processing.

Ability to: Apply auditing principles and procedures; analyze situations accurately and take effective action, including enforcement action, if appropriate; interpret, analyze, and apply State laws relating to workers' compensation benefits; analyze and summarize fact situations and workers' compensation laws and rules; determine whether proper medical treatment and benefits are being provided; obtain compliance with workers' compensation regulations; identify violations of workers' compensation regulations and make appropriate assessments of penalties; testify at appeal hearings on disputed audit findings; speak and write effectively; prepare clear, complete, concise reports; maintain effective relationships with those contacted in the course of work; use tact and good judgement.

Senior Workers Compensation Compliance Officer

Knowledge of: All of the above and specialized and complex program auditing practices and procedures; principles and theories of administrative law and judicial review of administrative actions; legal terms and forms in common use.

Ability to: All of the above, and conduct fair and impartial hearings in a manner that will obtain all pertinent evidence; make accurate summaries of evidence, prepare reasons for decisions, and make findings based on such facts.

Supervising Workers' Compensation Compliance Officer

Knowledge of: All of the above, and principles and practices of personnel management, training, and supervision; the Department's Affirmative Action Program objectives; a supervisor's role in the Affirmative Action Program and the processes available to meet affirmative action objectives.

Ability to: All of the above, and plan, organize, and administer an area-wide program; interpret and apply the policies and procedures of the Division of Workers' Compensation and the Department of Industrial Relations; as a supervisor, effectively contribute to the Department's affirmative action objectives.

Workers' Compensation Compliance Manager

Knowledge of: All of the above, and overall Division and Department purposes, policies, and procedures; principles and practices of public administration; statistical methods and computer technology used in workers' compensation programs and management information systems; medical and educational resources used in treatment of the industrially disabled; history and development of California workers' compensation law and of California and other disability rating schedules; a manager's role in the Affirmative Action Program and the processes available to meet affirmative action objectives.

Ability to: All of the above, and plan, organize, administer, and evaluate the operation of statewide ancillary workers' compensation programs and program staff; coordinate activities, policies, and procedures with other units of the Division of Workers' Compensation and the Department; utilize statistical methods and computer technology to ensure efficient program operations; as a manager, effectively contribute to the Department's affirmative action objectives.

Special Personal Characteristics

All Levels:

Willingness to travel and work irregular hours, tact and impartiality.

Additional Desirable Qualification

All Levels:

Possession of a valid California driver's license.

Class History