JOB TITLE: TORT CLAIMS EVALUATOR

JOB CODE: 70342

SERIES NATURE OF WORK: The Tort Claims job series describes work in the investigation, evaluation, negotiation, and disposition of tort claims that are filed against commonwealth agencies or entities due to agency or employee negligence.

DEFINITION: This is professional work in the investigation and adjudication of complex tort claims.

An employee in this job investigates complex bodily injury tort claims to determine liability and achieve settlement in a fair and expeditious manner. Work involves interviewing claimants and witnesses; obtaining and interpreting case evidence; traveling to incident locations to collect on-site evidence; recommending and consulting with subject matter experts; assessing liability and compensatory values; and determining claim eligibility under the Sovereign Immunity Act and authorizing, negotiating, or denying claim payments. Work includes drafting case summaries and formal reports, pursuing subrogation opportunities to recover losses, determining tort exposure and establishing reserves, and collaborating with commonwealth agencies to review claims and help mitigate risks. Work may also include serving as a lead worker over lower-level staff and reviewing investigative reports and settlement recommendations. Work is performed independently and reviewed by an administrative supervisor through observation and upon completion for adherence to procedures, standards, and timelines.

   DISTINGUISHING CHARACTERISTICS:

     • Work is distinguished from the lower-level job based on the responsibility for independently evaluating, negotiating, and settling complex claims such as those involving bodily injury, death, serious impairment of body function, or permanent body disfigurement.

     • Work at this level may involve functioning as a lead worker over Tort Claim Representative employees.

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.)

• Determines eligibility and liability of claims under the Sovereign Immunity Act.

• Manages complex tort claims that involve medical malpractice; serious injury such as total disability, extensive disfigurement, or death; and cases of complicated legal issues of negligence.

• Interviews witnesses, claimants, and other involved parties to record statements and verify information.

• Obtains and evaluates evidence such as accident and incident reports, photographs, witness statements, police and weather reports, insurance and health records, and other supportive documents.

• Interprets investigative findings to determine degree of negligence or liability and overall value of claim.

• Denies claims having no liability, doubtful liability, or comparatively less negligence than other parties.

• Reviews medical expense reports and property damage expenses to calculate and negotiate payment amounts.

• Authorizes claim payments within established settlement authority; prepares reports and justifications for settlement recommendations that exceed settlement authority.

• Functions as a lead worker by assigning and reviewing work, developing, and conducting training for Tort Claims Representatives, and performing quality control functions for automobile and property damage settlement decisions.

• Prepares formal investigative reports for cases and makes recommendations to commonwealth attorneys regarding unsettled cases.

• Estimates monetary reserve on all claims upon receipt for potential incurred loss.

• Researches the nature of tort claims and develops plans for agencies to mitigate risks.

• Researches subrogation opportunities and negotiates payment terms.

• Operates motor vehicles.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of the laws, regulations, and statutes related to third-party claims administration.

• Knowledge of the principles and practices of tort claims investigation, evaluation, negotiation, and disposition.

• Knowledge of investigative interviewing practices and techniques.

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

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

• Ability to inspect, analyze, and determine property and vehicle damages.

• Ability to prepare justifications based on the rules of evidence and discovery.

• Ability to operate a motor vehicle.

• 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)

• One year of experience as a Tort Claims Representative or Insurance Claims Evaluator 1 (commonwealth titles);

or

• One year of professional experience as a third-party claims adjuster, examiner, or investigator, and a bachelor’s degree;

or

• Four years of technical experience in evaluating or processing claims, or interviewing consumers to collect or review financial, insurance, or personal information to determine next actions, and one year of professional experience as a third-party claims adjuster, examiner, or investigator;

or

• An equivalent combination of experience and training.

SPECIAL REQUIREMENT:

• All positions require possession of an active motor vehicle license.