JOB TITLE: THIRD PARTY LIABILITY SPECIALIST

JOB CODE: 39680

SERIES NATURE OF WORK: The Third Party Liability (TPL) Specialist job series describes work in the evaluation and recovery of cash benefits and Medical Assistance (MA) expenditures against liable third parties, insurers, recipients, and probate estates.

DEFINITION: This is professional work in the review, evaluation, and recoupment of funds related to personal injury and estate recovery claims in the Department of Human Services (DHS).

An employee in this job reviews case files, identifies responsible third party entities, and recovers cash and MA claims from insurance carriers, attorneys, or other liable third parties. Work involves reviewing client files; communicating with medical providers, recipients, caseworkers, law enforcement agencies, and other pertinent parties to obtain and review additional case information; verifying and analyzing medical reports, insurance policies, managed healthcare plans, and MA benefit payments; researching, interpreting, and applying relevant federal and state MA regulations and other insurance plan provisions; independently determining if pursuing a third party is appropriate and whether collection efforts are feasible; and calculating and negotiating settlement payments. Work includes pursuing MA payments subject to estate recovery, updating and tracking all claim correspondence and payments in an electronic data system, and researching and resolving payment discrepancies. Work is performed independently and is reviewed by a Third Party Liability Specialist Supervisor through reports, conferences, and the attainment of program goals and objectives.

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.)

• Evaluates personal injury and estate claim referrals from county assistance offices, medical providers, attorneys, insurance carriers, state agencies, and automated information systems.

• Analyzes and verifies information pertaining to claims and ascertains the financial responsibilities of third party insurance providers.

• Collaborates with other DHS bureaus, state agencies, and county offices to recover payments for cash benefits, personal injury, workers’ compensation, medical malpractice, probate estates, and court-ordered restitution.

• Researches Pennsylvania insurance laws and commercial policies and interprets eligibility provisions to determine third party liability for MA programs.

• Applies estate recovery policies to recover MA costs from an individual's estate for hospital, nursing facility, home and community-based, and prescription drug services.

• Applies, interprets, and cites relevant laws, regulations, and policies to maximize cost recovery in personal injury and estate cases.

• Accesses data information systems to review, update, and maintain case files.

• Prepares case reports to support the department’s claims and testifies in court hearings.

• Closes cases when TPL payment is received, when it is determined that no TPL exists, or when payment is uncollectible.

• Participates in special training sessions and research projects.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES

• Knowledge of the principles and practices of data research, collection, and analysis

• Knowledge of the use and functionality of Microsoft Office Suite software.

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

• Ability to analyze and interpret numerical information.

• Ability to communicate effectively in writing.

• Ability to communicate effectively orally.

• Ability to establish and maintain effective working relationships.

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

• A bachelor’s degree;

or

• Four years of technical experience collecting, reviewing, or evaluating information for program eligibility or insurance limits of liability;

or

• An equivalent combination of experience and training.