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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00021642 |
Description Activated On: 3/12/2026 9:54:24 AM |
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. Provides clerical support to the Claims Division to ensure that claims system data is determined, entered, and accurately updated. |
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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. 1. Reviews cases in IT system and claims documentation to evaluate facts, dates, insurers, and health care providers and identify potential duplication of claim establishment. Correlates claims reports that are received with existing case files to avoid duplication and centralize all information for claims examiners further handling of claim file. Determines whether to open or close correlated claim files. 2. Interprets medical information in claims files to determine correct data codes. Updates IT system with claims coding information and entry in various Excel spreadsheets. 3. Verifies claim file information via file review, phone, email, fax and internet. Confirms current insurance carrier name, carrier contact name, defense attorney name, law firm name, law firm address, etc., in order to accurately correlate correspondence. Identifies and differentiates the varying roles of parties involved in claim litigation including insurance carrier representatives, defense versus plaintiff attorneys in order to direct letters, faxes, and other correspondence correctly. Utilizes court docket records to update trial dates in IT system. 4. Performs IT system claims file maintenance by entering information in databases and recording all changes on the C-416 Claim Report Form. Identifies incorrect information and notifies claims examiner and/or claims manager for review. 6. Verifies that severity code as submitted on C-416 Claim Report Form is accurate. This requires review of injury information provided within claims file materials and National Practitioners Data Bank (NPDB) code explanations to identify similarities or differences. Enters information in Excel spreadsheets. 7. Performs IT research of various County Court Dockets to identify litigation status such as trial, settled, continued, discontinued or dismissed. May include emailing a County Court contact to verify status of the lawsuit or the insurer contact to verify the status of their file. Completes comprehensive data determinations for entry into the claims IT system. Must have the ability to comprehend frequently used medical and claims terminology and make sound judgments. 8. Completes Claims History requests from Health Care Providers, Insurers, and credentialing entities. Checks verification of authorization documents in accordance with procedures. Generates Claims History in accordance with applicable coverage periods. Provides all information to Claims Manager or Administrative Officer for validity. Sends to external requesters accompanied by appropriate correspondence. 9. Serves as backup support in evaluating information submitted on Form C-416 claim report and associated attached documents such as legal complaint, writ of summons, letters from insurers, healthcare providers, medical records, attorney correspondence, etc. to assist in determination of Mcare coverage. 10. Prepares final form letters, prepares documents for emailing and mailing. Converts Word documents to PDF format prior to sending to outside sources via email. 11. Provides backup support to directing calls, answering general phone inquiries, and records room maintenance. 12. Provides other related clerical duties as assigned. Train other support staff for cross-task coverage. 11. Perform other duties/special projects as assigned. |
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. Work is performed with considerable independence and minimal supervision; changes in operational standards, procedures and work policies are discussed in detail with the unit manager / supervisor prior to implementation. Most work is self-directed and of a highly confidential nature. Some sensitive work must be authorized by manager and Mcare executive management. Reviews case information and makes independent decisions to open or close correlated claim files. Reviews claims history requests and documentation and makes independent decisions to fulfill the requested information or reject with reasons. Determines data and severity codes for claims files based on review of claims documentation. Interprets medical codes. |
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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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