12/05/2014 70356

STATE WORKERS’ INSURANCE FUND CLAIMS SERVICES DIVISION CHIEF

DEFINITION: This is professional administrative work directing the claims activities of the State Workers’ Insurance Fund (SWIF).

The employee in this job is responsible for planning and directing the claims examination, investigation, payment, and settlement programs of SWIF, and planning and directing the managed care and district office training programs. Work includes directing the reserve program to determine the amount of reserve funds required for claims; directing a commutation program to settle claims; directing SWIF’s managed care program to establish commonwealth-wide standards for the utilization of managed care services; directing the investigation program to determine liability for claims; and establishing training programs for district office personnel as well as for policyholders on Workers’ Compensation matters. Work also involves providing guidance on complex claims; answering questions and providing guidance in the application and interpretation of the Pennsylvania Workers’ Compensation, Occupational Disease, Federal Black Lung, and Longshore and Harbor Workers’ Compensation Act laws; and overseeing the referral of claims to rehabilitation and surveillance agencies. An important aspect of the work involves the development and implementation of policies and procedures to ensure effectiveness, efficiency, and consistency in the processing of claims and the interpretations of rules, regulations, and laws in all district offices. Supervision is exercised over subordinate managers and clerical personnel. Work is performed with considerable independence and is reviewed through conferences and reports for effectiveness and adherence to policy.

EXAMPLES OF WORK: Plans and directs the payment of federal and Pennsylvania Workers’ Compensation claims.

Directs the determination of reserve funds required to provide claims coverage and the settlement of claims.

Develops and implements operational policies and procedures for the investigation and processing of claims and the determination of liability.

Develops and enhances reporting tools to monitor the effectiveness of operations in the field.

Reviews and analyzes complex claims or claims with sudden shifts of liability.

Conducts meetings with staff and various state and federal representatives to resolve complaints and eliminate program barriers.

Ensures uniformity of operations and develops standards for the investigation of claims fraud in the field including when to conduct internal or contracted investigations.

Reviews and recommends claims for rehabilitation services, surveillance, reemployment services, or settlement.

Establishes State Workers’ Insurance Fund standards for the utilization of managed care services.

Oversees the development and delivery of training seminars for all claims personnel.

Answers questions from attorneys and state and federal agencies regarding the Pennsylvania Workers’ Compensation, Occupational Disease, Federal Black Lung, and Longshore and Harbor Workers’ Compensation programs.

Performs the full range of supervisory duties.

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

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Knowledge of the Pennsylvania Workers’ Compensation and Occupational Disease Laws.

Knowledge of the Federal Black Lung Program.

Knowledge of the principles and methods of program administration.

Knowledge of program evaluation methodology.

Knowledge of insurance principles and practices.

Knowledge of insurance laws and regulations.

Knowledge of the principles and practices of employee supervision.

Ability to read and interpret written material.

Ability to communicate effectively orally.

Ability to communicate effectively in writing.

Ability to establish and maintain effective working relationships.

MINIMUM EXPERIENCE AND TRAINING: Six years of professional program planning and analysis experience in the field of occupational compensation, liability insurance, or casualty insurance that includes two years of experience supervising the administration of Pennsylvania Workers’ Compensation, liability insurance, or casualty insurance claims;

or

An equivalent combination of experience and training that includes two years of experience supervising the administration of Pennsylvania Workers’ Compensation, liability insurance, or casualty insurance claims.