JOB TITLE: STATE WORKERS’ INSURANCE FUND CLAIMS SUPERVISOR

JOB CODE: 70352

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 and supervisory work in the evaluation and payment of SWIF workers’ compensation claims.

An employee in this job supervises SWIF claims staff in an assigned region in obtaining, verifying, and evaluating information to determine eligibility for workers’ compensation and occupational disease benefits to include the most complex and catastrophic injury claims. Work includes supervising staff responsible for establishing reserve funds for claims payments, processing indemnity and medical payments, and determining medical, employment and wage status of claimants. Work also involves providing interpretations and explanations of regulations, policies, guidelines, and administrative processes and methods to claimants, employers, and other concerned parties; reviewing investigative information applicable to specific types of workers’ compensation agreements or payments; authorizing the settlement of claims; and preparing documents and correspondence to support and explain decisions. Work may also involve supervising the processing, review, investigation, and payment of benefit claims under the federal Black Lung Benefits Act and Longshore and Harbor Workers’ Compensation Act. Work is reviewed through reports and conferences for conformance to departmental policies and program objectives.

DISTINGUISHING CHARACTERISTICS:

• Work at this level is distinguished from the lower-level job by supervising team staff in an assigned region.

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.)

• Supervises the determination of claims compensability under the Pennsylvania Workers’ Compensation Act, the Pennsylvania Occupational Disease Act, the federal Black Lung Benefits Act, and the Longshore and Harbor Workers’ Compensation Act.

• Supervises the investigation of workers’ compensation claims including third party involvement and occupational disease claims involving employees of SWIF policyholders.

• Supervises and provides guidance on the most complex and catastrophic injury claims.

• Supervises the evaluation of claims information and related reports and data necessary to render decisions on initial acceptance or denial of claims.

• Reviews and approves the acceptance or denial of claims within the statutory timeframes.

• Conducts periodic reviews of staff’s work to ensure compliance with workers’ compensation laws and regulations and with SWIF program guidelines.

• Identifies employee performance issues and addresses gaps in performance for additional training.

• Utilizes system analytics and reporting tools to assist in generating reports for SWIF management.

• Participates in large-loss conferences for claims with total incurred costs over a specified amount.

• Establishes a claim strategy for each claim reviewed and develops strategies for claims handling.

• Works with staff to identify potential fraud issues, ensures proper file documentation, and refers to SWIF fraud investigation staff.

• Oversees and coordinates the use of contracted services for medical management, surveillance, or vocational rehabilitation.

• Reviews and authorizes reserves and the settlement of claims within assigned authority levels.

• Performs the full range of supervisory duties.

• An 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 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 investigatory principles and techniques.

• Knowledge of interviewing practices and techniques.

• Knowledge of Microsoft Office Suite software programs.

• 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)

• Two years of experience as a SWIF Claims Adjuster (commonwealth title);

or

• Two years of technical experience as a workers’ compensation claims adjuster in the insurance industry;

or

• An equivalent combination of experience and training.