JOB TITLE: INSURANCE CLAIMS EVALUATOR 1

JOB CODE: 04321

SERIES NATURE OF WORK: The Insurance Claims job series describes work in the administration of special fund insurance claims.

DEFINITION: This is beginning level professional work in the evaluation and payment of special fund insurance claims.

An employee in this job analyzes and evaluates insurance claim files and recommendations submitted by a contracted Third Party Administrator (TPA) for the payment of insurance claims. Work includes reviewing claims information submitted by the TPA to ensure compliance with statutory requirements and claims administration practices, and for appropriateness of recommendations; approving payment of claims and contractor invoices; identifying and researching claim issues and providing recommendations to the supervisor for resolution; and contacting claimants, TPA staff, attorneys, service providers, and other individuals to collect or provide information regarding the status of claims. Work is performed under the direction and guidance of an Insurance Claims Manager or administrative supervisor.

EXAMPLES OF WORK: (NOTE: The examples of work are representative of the work, but every position classified to this job may not perform all examples of work listed. Conversely, this is not an all-inclusive list of work examples.):

• Reviews, audits, and approves contractor service invoices, provider payment authorizations, third party reviewer invoices, legal invoices, and third party settlements.

• Reviews and approves Compromise and Release requests and Direction Request documents.

• Reviews TPA requests for assistance and provides written recommendations regarding the handling of claims.

• Assists in the preparation of reports and briefings.

• Responds to questions from claimants, remediation consultants, providers, and attorneys regarding the status of benefits or payments.

• Audits TPA files to ensure files are maintained, documented, properly reserved, and adjusted in accordance with department policy, contract requirements, and applicable laws and regulations.

• Reviews claims status reports, loss run reports, and claim correspondence to ensure claims are administered in accordance with department procedures, contract requirements, and applicable laws and regulations.

• Establishes and monitors claim file legal reserves.

• Monitors TPA performance to ensure swift file handling and prompt claims payments during the takeover of a liquidated insurance carrier’s Workers’ Compensation claims.

• Assists in the preparation and maintenance of policy and procedure manuals.

• Assists in the preparation of Requests for Proposals for TPAs, actuarial services, and other services.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of the methods and techniques of insurance claims evaluation, investigation, and adjustment.

• Knowledge of insurance principles, practices, and terminology.

• Knowledge of regulations pertaining to payment of insurance claims.

• Ability to analyze and interpret claims information.

• Ability to communicate effectively orally.

• Ability to communicate effectively in writing.

• Ability to establish and maintain effective working relationships.

MINIMUM EXPERIENCE AND TRAINING: (NOTE: Based on the Entry Level Knowledges, Skills, and Abilities):

• One year of professional experience in the evaluation and payment of claims in multiple lines of insurance and a bachelor’s degree;

or

• An equivalent combination of experience and training.