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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 50272125 |
Description Activated On: 9/29/2025 11:51:38 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. 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. Completes an investigation for reported incidents/claims within 48 hours of receipt of the claim assignment and processes acceptance or denial within the time frame as prescribed by law. The investigation must include consideration of the course and scope, employment relationship and may include, but should not be limited to vehicle accident, coming and going, if appropriate to the assigned office, firefighter affiliation, undocumented worker, misclassification, and all other information that is necessary to determine compensability of the present claim. 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. Handles all aspects of minor disability/lost time claims with closed periods of disability or anticipated lost time of less than eight weeks. 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. 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. Manages and monitors claims on a continual basis to resolve ongoing exposures. Makes the initial decision of approval or denial on a reported work-related claim within their respective authority level. Recognizes the need for and recommends the use of Independent Medical Examinations (IME) and ensures the original job duty description is included in the IME request. Recognizes the need for filing of Utilization Review, refers to medical staff for review. 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, Notice of Compensation Payable agreements for compensation for disability, denial, and final receipts, etc. Responsible for issuance of ongoing indemnity payments, for period of short period of disability, notifies supervisor for reassignment of claim if disability exceeds eight weeks duration. All disability payments must be supported by medical reports with claim file documentation. 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. Process claim payment related vouchers as necessary and documents claim file with reasons for voucher payment. Utilizes system analytic tools to assist in management of assigned claims. 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. Maintain working knowledge of SWIF’s 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. Performs related work 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. 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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