Eligibility Adjudicator

Website Workplace Safety and Insurance Board

Job Description:

Manage cases that are allowed, denied, reconsidered or resolved within established program guidelines, following a structured case management framework to enable them to achieve high quality eligibility decisions and successful outcomes.

Job Responsibilities:

  • Ensuring accident reporting compliance with the employer.
  • Proactively collect information from workplace parties and healthcare providers required for eligibility decisions and respond to inquiries.
  • The employer is covered under the Act;
  • Support workplace parties in their return to work (RTW) efforts by sharing any available information about the workers’ capabilities and/or precautions.
  • Refer requests to appropriate internal WSIB parties (Nurse Consultant, Account Specialist, Legal Services) to gain their expertise on various components of a claim when the need for appropriate intervention is recognized and follow up with them as required.
  • Attempt to prevent or resolve disputes, handle requests for reconsideration and, if unresolved, arrange access and process the objection.
  • Inform parties of their rights, responsibilities and obligations under the WSI Act and applicable legislation, and the consequences of non-compliance.
  • Assess case and plan towards best outcomes. Make eligibility decisions quickly and accurately and communicate them, verbally and in writing by determining the following:
  • With the assistance of Payment Specialists where required, ensure appropriate earnings information is on file in order to determine the appropriate duration and level of benefits.
  • Review and monitor cases until closure or transition to a Case Manager, assessing RTW and recovery factors to differentiate cases requiring Case Manager expertise.
  • The diagnosis is compatible with the accident;
  • The injury is work-related;
  • Continuity and compatibility support ongoing entitlement in the case of recurrence;
  • Proof of accident can be established;
  • Perform other related duties as assigned or required such as participation in the development and implementation of business plans and projects.
  • The worker is employed by the employer at the time of the injury;

Job Requirements:

  • Two years prior experience in adjudication and customer service.
  • University completion at undergraduate level.

Job Details:

Company: Workplace Safety and Insurance Board

Job Category: Government

Vacancy Type: Full Time

Job Location: Hamilton, Ontario, CA

Application Deadline: N/A

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