JOB TITLE: STATE WORKERS’ INSURANCE FUND CLAIMS REPRESENTATIVE

JOB CODE: 70350

SERIES NATURE OF WORK: The State Workers’ Insurance Fund (SWIF) Claims Adjuster job series describes work in the investigation, review, processing, reserving, and payment of workers’ compensation and occupational disease claims administered by SWIF.

DEFINITION: This is entry level technical work in the review, evaluation, and payment of SWIF workers’ compensation insurance claims.

An employee in this job reviews, administers, and evaluates workers’ compensation claims to ensure compliance with the applicable statute and claims administration practices, approves payment of medical-only claims and minor lost time/disability claims, and identifies claims issues for referral or resolution. Work also involves contacting claimants, service providers, and other individuals to collect or provide information regarding the status of claims. Work is performed under the general direction of a SWIF Claims 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.)

• Investigates, processes, and administers medical only claims and minor lost time/disability claims with closed periods of disability of less than eight weeks.

• Sets claims file monetary reserves within assigned authority for potential incurred losses and administers claims against such reserves.

• Makes the initial decision of approval or denial on a reported work-related claim within assigned authority level and processes acceptance or denial within the timeframe prescribed by law.

• Handles medical only as well as lost time claims with closed periods of disability by determining liability for lost wages and medical bills, processing bill payments, monitoring and managing medical treatment, and closing files when appropriate.

• Reviews, approves, and makes payments of medical only bill claims and bills from contract and medical service providers.

• Identifies and makes recommendations to supervisor of suspected excess use of medical treatment(s).

• Sets claims file monetary reserves for potential incurred losses within assigned authority and administers claims against such reserves.

• Contacts appropriate parties regarding the status of benefit payments.

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

• Identifies and reports potential fraud situations to SWIF fraud staff or supervisor.

• Identifies potential subrogation and claims issues and brings information to the supervisor.

• Determines need for independent medical examination and prepares necessary information.

• Recognizes need for filing of utilization review and refers file to medical staff for review.

• Processes claims payment-related vouchers and updates files.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of insurance principles, practices, and terminology.

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

• Ability to analyze and interpret medical or health related 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)

• Two years of clerical work experience that includes collecting, recording, compiling, or preparing documents for medical, health, or work-related insurance claims;

or

• An equivalent combination of experience and training.