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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00285453 |
Description Activated On: 3/17/2026 1:28:24 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. To receive and process initial claims report forms (C-416 Form) resource account for use in establishing claims and other aspects of claims operations. Cross function of completing claims history requests and legal invoice review. |
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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. Receives claim initial report forms (C-416) via electronic and mail forwarding from insurers for overall claim establishment or rejection within entry point determination. Must effectively communicate verbally and in written correspondence – email/fax/letters with insurers and health care providers. This job is front line analysis of claim information received and potential applicable coverage for the claim. Specific description of accomplishments as follows: 1. Reviews information submitted on Form C-416 claim report at mail receipt point from dedicated resource account, mail and fax with associated attached documents such as legal complaint, writ of summons, letters from insurers, healthcare providers, medical records, attorney correspondence, etc. to determine whether Mcare coverage should apply. Specifically, must compare health care provider for whom coverage is being requested and determine whether the names and dates of coverage correlate with the reporting insurer and named health care provider. 2. Preliminarily compare coverage system information of reported healthcare provider to C-416 to alert supervisor of no coverage existing in coverage system. Checks system data base and mail logs for prior receipt of claim to determine duplication by same or other insurer and responds accordingly. Determines if more information is required from insurer or healthcare provider before acknowledging receipt of initial claim form based on own judgment. Consults claims managers, claim entry technicians and supervisor when necessary. 3. Initiates the process to generate the appropriate responses to insurers/health care providers either in writing or telephonic to communicate acceptance or rejection of initial claim form submitted, including communicating applicable Mcare policies and procedures, specifying form deficiencies, establishing time period for responses in order for processing of initial claims report to proceed to next step. 4. Maintains a diary of pending claims awaiting additional information from insurers for initial claim report process. Tracks and notifies insurers/ healthcare providers of unacceptable submissions and analyzes newly received information. Maintains the spreadsheet for all C-416 Forms received from insurers for missing or incomplete information. 5. Prints file copies and stages for processing by claim entry technicians. Enters information in spreadsheet and DocuShare database for critical documentation. 6. Researches claims system by analyzing facts, dates, insurers, and health care providers for potential duplication of claim establishment. Correlates claims that are accepted within existing case files to avoid duplication and centralize all information for claims examiners further handling of claim file. 7. Makes recommendations regarding patterns and practices of insurers and health care providers and reports to appropriate Mcare management. 8. Responsible as backup for completing claims history requests from healthcare providers and credentialing entities. Verifies proper authorization documents in accordance with procedures in order to release confidential claims history information. Generates claims history reports in accordance with applicable coverage periods requested. Provides all information to claims manager or administrative officer for validation. Sends to the requesters (healthcare provider, insurance broker or other identified entity) accompanied by appropriate correspondence. 9. Responsible for initial receipt and screening of legal invoices received from contract firms. Checks for proper completion of invoice face sheet form (FB-1A.) Returns improperly prepared forms for resubmission or forwards to invoice entry staff for further analysis and payment. 10. Assists in training of other personnel on claims receipt procedures and loss history responses. 11. All other duties as may be assigned by supervisor, such as assisting in answering multi-line phone system. 12. Executes all special projects assigned by Supervisor. |
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 if initial claim form reported by insurers is acceptable in format and duplicative. Determines missing information and communicates verbally and written with insurers and healthcare providers. Correlates claims that are accepted with existing case files to avoid duplication and centralize all information for claims examiners further handling of claim file. Initial review of legal invoices for proper completion. Verifies and completes processing of requests for claims history used in insurance and credentialing. Handles sensitive and confidential information. |
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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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