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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00011859 |
Description Activated On: 4/14/2026 12:19:19 PM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. Investigates, processes, and manages reported work related claims/injuries for employees of policy holders covered by the State Workers’ Insurance Fund for the purpose of determining compensability. Monitors and controls all aspects of the claim to conclusion in accordance with established authority and procedure. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. Investigates, processes, and manages reported work related claims/injuries for employees of policy holders covered by the State Workers’ Insurance Fund for the purpose of determining compensability. Monitors and controls all aspects of the claim to conclusion in accordance with established authority and procedure. office, firefighter affiliation, undocumented worker, and misclassification. Recommends surveillance relating to assigned claims. Reviews and makes determination relating to applicability of pre-existing conditions and impact on claims. In compliance with Section 301 (c) (1) of the Workers’ Compensation (WC) Act. In applicable District Office, completes investigation for firefighter claims including but not limited to membership roster, assigned duties by chief, covered non-firefighter duties approved by the municipality. Makes compensability determination based upon Section 601 of the WC Act. Makes determinations to identify potential fraud, documents and reports all suspected fraud to the SWIF fraud investigator and supervisor. Identifies and makes recommendations to supervisor when identified excess use of Physical Therapy or Durable Medical Equipment supplies have been ongoing for an extended/excessive period of time. Monitors disability status in relationship to the ODG guidelines, determines reason for deviations determinations appropriate action needed to conclude within guidelines Identifies claims with potential subrogation from the start of the claim and provides proper notification to legal within the operating system and conducts third party investigation. Determines application of specific loss provisions of the WC Act when warranted. Takes appropriate action to limit claim exposure to specific loss payment when appropriate. Documents within the operating system and manages the process. Ensures claim intake data is complete and accurate including but not limited to claimant data, employer data, NAICS and incident information. Ensures I-9 documents are included within the policy file and notifies underwriting if not in file. Contacts appropriate parties related to the reported claim including claimant, employers, doctors, hospitals, and witnesses to determine eligibility for workers’ compensation benefits. Determines if a claimant is prescribed opioids and if so conducts a claim review on a regular basis. Alerts supervisor if treatment does not align with workers’ compensation opioid prescribing guidelines. Ensure drug screenings match script activity. Makes determination if a return-to-work plan / light duty plan is warranted and manages process if applicable. Determinations if a labor market survey is warranted and manages process if applicable. Manages and monitors claims on a continual basis to resolve ongoing exposures. Makes the initial decision of acceptance or denial of a reported work-related claim within their respective authority level. Recognizes the need for and recommends the use of Independent Medical Examinations (IME), ensures the original job duty description is included in the IME request. Recognizes the need for filing of Utilization Review and refers to medical staff for review. Recommends a medical fee review filing, and processes when applicable. Creates fact-based claim reserves within authority level with proper file documentation. Reviews and processes EDI transactions as warranted including First Report of Injury/Supplemental Report of Injury transactions, and acknowledgement transaction rejections and making corrections on assigned claims. Makes claim determination, completes all required LIBC-forms on a claim, including, but not limited to, accept, Temporary Notice of Compensation Payable, Notices of Compensation payable agreements for compensation for disability, denial, and final receipts, etc. Determines if form LIBC-756 is warranted for offset and manages process if warranted. Monitors and determines if indemnity payments are being paid for extended periods without medical treatment. If applicable takes appropriate actions to mitigate circumstances. Responsible for issuance of ongoing indemnity payments supported by medical documentation. Conduct wage checks throughout the claim process. Determines liability on all medical bills submitted on assigned claim; processes medical bill payments, monitors and manages the medical treatment and closes medical when appropriate to do so. Determines if there are Medicare eligible impacts on assigned claims. If applicable, manages the process including identification of Medicare status and Medicare Set-Aside proposal. Process claims payment related vouchers as necessary. Documents claim file with reason/s for voucher payment. Utilizes system analytic tools to assist in management of assigned claims. Determines need for and appropriate assignment of claim to medical case management and vocational rehabilitation. Pursues Compromise and Release settlements where warranted within settlement authority on assigned assigned claims. Determines interest on claim prior to settlement discussions.. Review assigned claim litigation decisions and take appropriate action based on outcomes (example - appeal, issue forms, petitions). Follow-up on all actions taken including but not limited to termination petitions, Temporary Total Disability benefits, and confirm proper outcomes have been acted upon. Makes determinations related to fatal claims including but not limited to filing of LIBC-338, LIBC-339. Manages Black Lung, Longshore cases and Occupational Disease cases as assigned. Maintain working knowledge of SWIF’s SMART computer system and access required information, such as, verifying employer’s coverage, payment status of claims (indemnity and medical), claim numbers and other related fields as required. Pay claims through SWIFs computer systems by completing all necessary screens after the completion of the investigation. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. Determines compensability and management of claims upon the completion of an investigation. Sets fact-based reserves for claims within authority and meets with Claims Supervisor for periodic meetings to discuss claim status. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. 5. 6. |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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