JOB TITLE: INSURANCE OMBUDSMAN, PID

JOB CODE: 04125

DEFINITION: This is professional administrative work directing the Pennsylvania Insurance Department’s (PID) consumer advocacy program and outreach activities for all insurance product lines.

The employee in this job provides intermediary services between consumers and insurance companies or other parties by facilitating communication, resolving impasses, and advocating for fair and legal resolutions on behalf of the consumer. Work involves developing and implementing policies, procedures, and initiatives to support state-wide consumer outreach, education, and advocacy objectives; assessing consumer complaints and serving as a mediator between consumers and insurance companies to resolve complex, extra-jurisdictional, or high-profile insurance-related complaints not under PID’s regulatory authority and across multiple product lines; analyzing complaint trends and industry practices to identify patterns and systemic issues with insurance companies and recommending program changes to protect consumers; and examining current and proposed legislation, regulations, and policies for potential impact on consumers and PID goals and objectives. Work includes representing the department with high-level insurance-related interest groups and serving as the department spokesperson for high-profile consumer insurance-related issues. Work is performed independently under the general direction of the office director and is reviewed through conferences, written reports, and the evaluation of program results.

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.)

• Plans, develops, and coordinates PID’s consumer advocacy program.

• Develops policies and procedures to ensure consumer outreach, education, and advocacy goals and objectives are met.

• Advocates on behalf of consumers utilizing insurance policies across multiple product lines.

• Represents the agency as an intermediary between consumers, insurance companies, and other parties to mediate disputes and avoid formal legal action.

• Analyzes insurance policies to determine coverage, exclusions, and conditions related to complex, extra-jurisdictional, or high-profile insurance-related complaints.

• Provides advocacy, mediation services, and compliance assistance to consumers and recommends actions the consumer could take to attempt to resolve their claim before pursuing formal legal action.

• Analyzes current and proposed legislation, identifies potential consumer impacts, and provides recommendations on changes in support of consumer concerns, rights, protections, and needs.

• Represents PID with insurance-related interest groups, trade associations, service providers, consumer advocacy groups, chambers of commerce, legislators, and the public, and serves as a subject matter expert at public education events.

• Develops and coordinates outreach activities and educational presentations to provide information to consumers on their rights, protections, and options as they pertain to their insurance coverage and on navigating complaints and disputes.

• Prepares detailed reports for agency executive leadership highlighting program achievements and downfalls and makes recommendations for improvements.

• 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.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of insurance laws, rules, and regulations that govern payment disputes and consumer protection statutes.

• Knowledge of insurance principles, products, and terminology across major product lines.

• Knowledge of the methods and techniques of insurance claims investigation and evaluation.

• Knowledge of the responsibilities of consumers under various insurance laws.

• Knowledge of insurance claim procedures and processing workflows.

• Knowledge of dispute resolution, conflict deescalation, and negotiation techniques.

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

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

• Ability to conduct financial and statistical studies and prepare accurate and comprehensive reports.

• 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)

• Five years of professional experience in insurance underwriting, insurance claims adjusting, brokering insurance coverage, selling and servicing insurance policies, auditing and examining insurance companies, conducting insurance investigations, or advocating on behalf of insurance claimants; and a bachelor’s degree in business administration, management science, marketing, public administration, risk management and insurance, communications, education, law, or a related field;

or

• Three years of professional experience in insurance underwriting, insurance claims adjusting, brokering insurance coverage, selling and servicing insurance policies, auditing and examining insurance companies, conducting insurance investigations, or advocating on behalf of insurance claimants; and a master’s degree in laws, studies in law, dispute resolution, or jurisprudence;

or

• Two years of professional experience in insurance underwriting, insurance claims adjusting, brokering insurance coverage, selling and servicing insurance policies, auditing and examining insurance companies, conducting insurance investigations, or advocating on behalf of insurance claimants; and a juris doctorate;

or

• An equivalent combination of experience and training.