JOB TITLE: INSURANCE CLAIMS MANAGER

JOB CODE: 04335

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

DEFINITION: This is management work directing the Auto CAT and Workers’ Compensation Security Funds Division or the Underground Storage Tank Indemnification Fund Division in the Bureau of Special Funds within the Pennsylvania Insurance Department.

An employee in this job manages insurance claims administration for the Underground Storage Tank Indemnification Fund (USTIF) or for the Catastrophic Loss Benefits Continuation (Auto CAT) and Workers’ Compensation Security Funds. Work includes planning and directing the activities of insurance claims staff responsible for evaluating insurance claim files and recommendations submitted by contracted third party claims administrators for payment of insurance claims; managing third party claims administrators; directing outside counsel responsible for the defense of insurance claims and initiation of legal action; and authorizing claim payments and settlements. Work also involves developing procedures for the determination of eligibility and payment of claims; coordinating with an actuarial firm to develop a plan for the collection of fees to assure funds are available for the payment of claims; negotiating subrogation, reinsurance, and large insurance claims settlements; and appearing as an expert witness on behalf of the commonwealth on exceptions to insurance claims, assessments, and criminal and civil cases. Supervision is exercised over a staff of professional and clerical employees. Work is performed under the general direction of the Director, Bureau of Special Funds and is reviewed for effectiveness through conferences and reports.

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.):

• Plans, manages, and coordinates the activities of staff engaged in the evaluation and payment of claims to eligible parties.

• Manages claims services provided by a third party administrator (TPA) and ensures adherence to service level agreements.

• Provides advice and consultation to TPA staff on complicated claim issues.

• Develops operational policies and procedures.

• Analyzes budget information and assists in the preparation of annual fund operating budgets.

• Prepares Requests for Proposals for required services and chairs selection committees.

• Negotiates contract changes with the TPA, actuarial firm, and other service providers.

• Adjudicates claim appeals for the Auto CAT and Workers’ Compensation Security Funds.

• Reviews and approves TPA requests for rehabilitation services, attorney services, commutations negotiations, provider payment authorizations, supporting invoices, and third party settlements.

• Develops and prepares insurance claim audit plans to ensure that claim files are being maintained and adjusted in accordance with departmental policy.

• Performs research on general claims issues and on specific claim files and prepares written reports and responses.

• Represents USTIF, the Workers’ Compensation Security Fund, or the Auto CAT Fund by giving presentations at local, state, and national meetings and conferences on related issues and topics.

• Presents claims information quarterly at Underground Storage Tank Indemnification Board meetings.

• Coordinates the preparation of annual fund reports.

• Coordinates responses to legislative inquiries.

• Performs the full range of supervisory duties.

• Employees in this job may participate in the performance of subordinates’ work consistent with operational or organizational requirements.

• 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.

• Knowledge of basic negotiation principles and practices.

• Ability to analyze and interpret claims information.

• Ability to analyze and interpret policies, procedures, and regulations.

• Ability to establish and maintain effective working relationships.

• Ability to communicate effectively orally.

• Ability to communicate effectively in writing.

FULL PERFORMANCE KNOWLEDGES, SKILLS, AND ABILITIES: (NOTE: These are expected of an employee performing the work of this job at the full performance level. These may not be evaluated by the State Civil Service Commission or used for Civil Service examination purposes and are not position-specific performance standards.):

• Knowledge of laws and regulations pertaining to the fund(s) for which claims administration is managed.

• Knowledge of the principles and practices of supervision.

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

• Three years as an Insurance Claims Evaluator 2;

or

• Five 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.