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Claims examiner standards

Insurers – including self-insured employers and service companies – must employ claims examiners who are certified or who qualify as a claims examiner trainee or a temporary claims examiner. The Workers’ Compensation Division (WCD) does not administer tests or issue certifications. It is up to insurers to develop training curricula and administer examinations. Training may be provided in the form of seminars, workshops, association meetings, forums, correspondences, video, and similar courses. 

Certification

For the initial certification, the claims examiner must satisfactorily complete an examination administered by the insurer. The examination must demonstrate an individual’s familiarity and understanding of the workers’ compensation statutes and rules, in addition to his or her ability to perform claims processing activities. The certification is effective from the date of the examination and lasts for a three-year period. 

To renew the certification, the claims examiner must complete 24 hours of continuing education training during the current certification period. The training must include at least six hours of training related to workers’ compensation statutes, administrative rules, and case law. It must also include at least one hour of training related to interactions with independent medical examination providers. Additional training may cover medical case management, communication, and claims processing skills relevant to Oregon workers’ compensation claims.

Within strict limitations, claims processing duties may be performed by claims examiner trainees or temporary claims examiners. 

Recordkeeping

All insurers processing Oregon workers’ compensation claims must maintain records of their claims examiners employed to process claims. These records are subject to inspection or audit by the Workers’ Compensation Division. Certified claims examiners may also want to maintain copies of these records.

These records must include the following:

  • Identification of all certified claims examiners, with the following information:
    • Verifiable documentation of current certification
    • Beginning and ending dates of these certifications
  • Identification of all temporary claims examiners, with the following information:
    • Documentation verifying the two-year experience requirement
    • Dates of employment within the past 24 months
    • Name of supervising certified claims examiners
  • Identification of all claims examiners trainees, with the following information:
    • Dates of employment within the past 5 years
    • Name of supervising certified claims examiner
  • Records of qualified training for certified claims examiners, subsequent to the most recent certification, with the following information:
    • Name of instructions
    • Syllabus or description of subject matter
    • Dates of training
    • Times of training
    • Hours of training
    • Type of training.
  • Records supporting initial acknowledgements of certification and renewals issues by the insurer

Contact

800-452-0288 (toll-free)
Barb Belcher:​ 503-947-7687
Fax: 503-947-7725
wcd.askanauditor@oregon.gov​

Receive updates to audit information

Resources

Annual audit methodology
Focused audit methodology​​​​​​​​​​​​​​​

Related rule

OAR 436-055

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