JOB TITLE: INSURANCE CLAIMS EVALUATOR 2

JOB CODE: 04322

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

DEFINITION: This is 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 claim 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 also involves providing guidance to TPA staff on interpreting regulations and policies. Work is performed independently under the general direction of an Insurance Claims Manager or administrative supervisor.

DISTINGUISHING CHARACTERISTICS:

•Work at this level is differentiated from the lower level job by the greater independence and the responsibility for authorizing direct claim payments up to$250,000.

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 complex claims.

•Assists in the preparation of Requests for Proposals for TPAs, actuarial services, and other services by drafting statements of work and other related documents and leads selection committees.

•Answers questions from claimants, providers, attorneys, remediation consultants, government agencies, and legislative staff regarding the status of benefits or payments.

•Reviews claim 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.

• Drafts attorney assignment memorandums.

• Oversees complex litigation files.

• 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 and prepares reports of findings.

• Identifies and researches potential subrogation and claims issues and provides effective recommendations for resolution.

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

• 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 experience as an Insurance Claims Evaluator 1;

or

• Two years 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.