JOB TITLE: STATE WORKERS’ INSURANCE FUND CLAIMS ADJUSTER

JOB CODE: 70351

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 advanced technical work in the processing, review, investigation, and payment of workers’ compensation and occupational disease claims administered by SWIF.

An employee in this job is responsible for obtaining, verifying, and evaluating information to determine eligibility for workers’ compensation and occupational disease claims to include the most complex and catastrophic injury claims. Work may also include the processing, review, investigation, and disbursement of funds for the federal Black Lung Benefits Act and Longshore and Harbor Workers’ Compensation Act benefit claims. Work is reviewed by a SWIF Claims Supervisor for completeness of assignments, appropriate analysis of information, development of sound recommendations, and case handling decisions.

DISTINGUISHING CHARACTERISTICS:

• Work at this level is differentiated from the SWIF Claims Representative job by the responsibility for authorizing non-catastrophic injury claims in excess of eight weeks of disability, and managing the most complex and catastrophic claims.

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 manages work-related disability/injury claims for determining compensability for claims that have anticipated disability periods in excess of eight weeks or are the most complex work-related claims and injuries for employees of SWIF policyholders.

• Reviews and evaluates injury, medical, investigatory, and related reports and data to render initial acceptance or denial of claims in accordance with established guidelines and within the respective authority level.

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

• Reviews and makes determinations on the applicability and impact of pre-existing conditions on claims.

• Manages reinsurance/excess coverage by reporting claims to reinsurance/excess coverage carriers and submitting necessary documentation to recover funds.

• Identifies claims with potential subrogation, conducts third party investigations, and provides proper notification to legal.

• Determines if labor market survey is warranted and manages the process.

• Recognizes the need for and recommends the use of Independent Medical Examinations (IME), Impairment Rating Evaluations (IRE), surveillance, and the filing of utilization reviews; and prepares claim information for IME/IRE.

• Makes determinations to identify potential fraud, and documents and reports all suspected fraud to SWIF fraud staff and supervisor.

• Identifies and makes recommendations to supervisor of suspected excess use of physical therapy or durable medical equipment.

• Reviews, analyzes, and compiles data and information for case files concerning claimants suspected of abusing or defrauding the program.

• Conducts investigations of claims and occupational exposures including third party claims to secure information needed to establish liability; and contacts third parties, private insurance carriers, and legal representatives in connection with claims management.

• Determines if specific loss provisions apply to the claim and takes appropriate action to limit claim exposure to specific loss payment.

• Makes determination if a return to work plan or light duty work plan is warranted and manages the process if applicable.

• Recognizes the need for and recommends the use of independent medical examinations, impairment rating evaluations, surveillance, and the filing of utilization reviews.

• Coordinates and handles litigation management activities associated with assigned claims, including reviewing litigation decisions, to ensure a timely and cost-effective resolution; and takes appropriate action based on outcomes.

• Pursues compromise and release settlements, where warranted, within settlement authority on assigned claims.

• Determines if there are Medicare-eligible impacts on assigned claim and, if applicable, manages the process, including the Medicare status and Medicare Set Aside proposal.

• Utilizes analytical tools to assist in the management of assigned claims.

• Handles future medical exposures on claims in which indemnity payments have been closed.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of the methods and techniques of workers’ compensation insurance claims evaluation, investigation, and adjustment.

• Knowledge of workers’ compensation insurance principles, practices, and terminology.

• Knowledge of regulations and laws pertaining to the payment of workers’ compensation claims.

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

• Ability to analyze and interpret 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)

• One year of experience as a SWIF Claims Representative (commonwealth title);

or

• One year of technical work in the processing, review, investigation, and payment of workers’ compensation insurance claims in the insurance industry;

or

• An equivalent combination of experience and training.