12/05/2014 70386

STATE WORKERS’ INSURANCE FUND CLAIMS SERVICES COORDINATOR

DEFINITION: This is specialized administrative work performing consultation and quality assurance for workers’ compensation claims administered by the State Workers’ Insurance Fund (SWIF).

An employee in this job is responsible for conducting a quality assurance and consultative program for workers’ compensation claims administered by State Workers’ Insurance Fund district offices. Work involves monitoring, analyzing, and ensuring the effectiveness, efficiency, and consistency in the processing of claims; ensuring compliance with Pennsylvania Workers’ Compensation, Occupational Disease, Federal Black Lung, and Longshore and Harbor Workers’ Compensation laws, and with established operating policies and procedures; recommending and developing policies, procedures, and training programs in order to improve district office accuracy, compliance, and efficiency in processing claims; and serving as liaison to public and private sector representatives to address questions related to claims and to provide guidance for occupational disease issues. Work also involves consultation on complex claims to ensure claims are handled effectively and in accordance with all appropriate laws, policies, and procedures. Work may include oversight of a SWIF district office or supervision of SWIF Reservists in the determination of reserve funds required for claims. Work is performed independently and is reviewed through conferences and reports.

EXAMPLES OF WORK: Conducts a quality assurance and consultative program to ensure the effective, efficient, and consistent processing of claims.

Conducts quality assurance reviews of SWIF district office claims to review for accuracy, timeliness, and compliance with all Pennsylvania Workers’ Compensation, Occupational Disease, Federal Black Lung, and Longshore and Harbor Workers’ Compensation laws as well as State Workers’ Insurance Fund policies and procedures.

Develops and recommends policies, procedures, and training to improve the claims operations.

Reviews and analyzes claims cases when compensation is questionable, and may approve or refer the claim to legal counsel for further determination.

Reviews claims investigation reports to determine if the Fund is liable or may deny the claim if not judged to be in accordance with the law, and directs further investigation if required.

Conducts meetings with various public sector agencies to resolve complaints and eliminate program barriers.

Supervises the determination of reserve funds for work related injury and occupational disease claims.

Oversees the operation and performance of SWIF district offices.

Answers questions from attorneys, claimants, or other parties involved in a claim regarding Commonwealth laws, regulations, Federal Black Lung Law, or the Workers’ Compensation Act in person, by telephone, or through correspondence.

Establishes and maintains cooperative working relationships within the agency, other governmental agencies, and the public.

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.

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.

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: Four years experience in the development, evaluation, or implementation of a program encompassing the processing, review, investigation, and payment of work-related insurance claims that included basic reserve funding determinations under state and federal laws;

or

An equivalent combination of experience and training.