TENTATIVE

                                                                                                                  Occ. Code 2502100

New York State Department of Civil Service

Classification Standard

BRIEF DESCRIPTION OF CLASS SERIES

            Positions in this title series process workers compensation or disability benefits claims filed with the New York State Insurance Fund (SIF).  Incumbents examine accident and medical reports to determine compensability and liability; analyze claims records and initiate proper processing procedures; examine medical bills and authorize payment; and negotiate an adjustment or recommend arbitration.

            These positions are found only at SIF.

DISTINGUISHING CHARACTERISTICS

            ASSISTANT CLAIMS SERVICES REPRESENTATIVE:  entry level; processes the more routine workers compensation or disability benefits claims.

            CLAIMS SERVICES REPRESENTATIVE 1:  full performance level; oversees all aspects of workers compensation and disability benefits claims processing; provides assistance to claimants, medical care providers, and policyholders on compensation and disability benefit claims.

            CLAIMS SERVICES REPRESENTATIVE 2:  first supervisory level; supervises claims operations for an assigned team; advises subordinate claims staff on the more difficult, sensitive, controversial, and/or high cost claims; coordinates and reviews the teams assigned accounts and/or caseloads.

            CLAIMS SERVICES REPRESENTATIVE 3: second supervisory level; coordinates claims activities across multiple units to ensure consistency among staff; negotiates settlements in the most significant medical and financial cases.

RELATED CLASSES

            Workers Compensation Examiners receive and process injured workers claims for benefits under the Workers Compensation Benefits, Disability Benefits, Volunteer Firefighters Benefits, Volunteer Ambulance Workers Benefits, and Volunteer Civil Defense Workers Benefits Laws and related rules and regulations.  Incumbents analyze employers reports of injury, medical reports from physicians/health care providers, calculate benefits due, manage claimants cases and prepare information for adjudication.  Positions may monitor compliance by employers, medical practitioners, insurance carriers and other parties of interest. 

            Policyholder Services Representatives solicit new business for SIF and provide account and risk management services; and perform policy analysis for workers compensation insurance policies at all premium levels.

            Underwriters assess and define the insurance risk assumed by SIF and perform technical services in underwriting workers compensation and disability benefits claims with SIF.

ILLUSTRATIVE DUTIES

ASSISTANT CLAIMS SERVICES REPRESENTATIVE:  under close supervision, develops and processes workers' compensation or disability benefits claims; organizes claims files; examines accident and medical reports to determine compensability and liability; analyzes claims records and initiates proper processing routines; examines medical bills and authorizes payment; negotiates an adjustment or recommends arbitration; recommends investigation of cases and prepares cases for hearings; issues payments for lower exposure compensation claims; assesses subrogation recovery potential and pursues accordingly; closes files within prescribed timeframes as determined by performance measures; refers cases for Section 32 settlement to higher-level claims staff; determines the compensability and liability of claims relating to cancelled policies; answers written and telephone inquiries from claimants, attorneys, doctors, vendors and employers; and assists higher level claims staff on more difficult and higher valued claims.

            CLAIMS SERVICES REPRESENTATIVE 1:  under the general supervision of a Claims Services Representative 2, oversees all aspects of workers compensation and disability benefits claims processing from inception to closing; initially determines the compensability of claims and files appropriate documentation with the Workers Compensation Board (WCB); calculates and adjusts reserves consistent with case analysis over the anticipated life of the claim; recommends cases for appeal to WCB; negotiates and/or makes recommendations regarding lump sum settlements; issues payments and requests for reimbursement where claims for supplemental benefits are involved; reviews awards to ensure the correct recipient and rate of compensation; schedules or waives medical examinations as necessary; analyzes medical bills to determine causality, levels of treatment, necessity for treatment, appropriateness of fees and procedure codes, and apportionment status; responds to requests for home modifications, home health care personnel, medication, and medical supplies and appliances; negotiates billing adjustments with medical care providers and suppliers applying workers compensation fee schedules and rules; identifies and initiates referrals to the Legal Department; and reviews case activity and determines when a claim can be retired.

            CLAIMS SERVICES REPRESENTATIVE 2:  under the general supervision of a Claims Services Representative 3, provides technical assistance and guidance on the more difficult, sensitive, and/or high cost claims; administers the more controversial claims and personally resolves all highly sensitive claimant complaints; oversees payment of the larger lump sum settlements and awards; establishes and implements appropriate changes to attain required performance levels that are consistent with Statewide claims policies and procedures; coordinates team workload to optimize efforts and identify priority issues; coordinates the delivery of training to staff; and represents SIF at meetings with other State agencies, assureds and insurance industry organizations.

            CLAIMS SERVICES REPRESENTATIVE 3:  under the general supervision of an Insurance Fund Business Manager, monitors the effective and efficient operation of claims/medical teams; oversees the assignment of cases to Hearing Representatives, outside legal staff, Counsel, and the Supervising Medical Care Representative; personally negotiates the most critical settlements; provides technical assistance in connection with special case or procedural problems affecting the Claims Department; informs the Insurance Fund Business Manager of any concerns regarding assureds, claimants and providers; represents the District Office at meetings with assureds and insurance industry organizations; analyzes Claims Department production reports and recommends necessary procedural changes and work reassignments to maintain or improve production levels; and serves on regional or Statewide committees such as the high cost case committee.

MINIMUM QUALIFICATIONS

            ASSISTANT CLAIMS SERVICES REPRESENTATIVE

Open Competitive:  four years of customer service experience, one year of which must have been in an insurance industry setting.  Sixty college credit hours may substitute for two years of the general customer service experience.

Promotion: one year of service at SIF in a position allocated to Grade 6 or higher.

            CLAIMS SERVICES REPRESENTATIVE 1

Open Competitive:  Bachelors Degree and satisfactory completion of a two-year traineeship.

            CLAIMS SERVICES REPRESENTATIVE 2

Promotion: one year of service as a Claims Services Representative 1, Insurance Fund Hearing Representative, Compensation Claims Investigator 2, or Medical Care Representative; or in a position allocated to Grade 18 or higher at SIF.

            CLAIMS SERVICES REPRESENTATIVE 3

Promotion: one year of service as a Claims Services Representative 2; Insurance Fund Hearing Representative; Compensation Claims Investigator 3; or Supervising Medical Care Representative.

Date:  3/09

NOTE:  Classification Standards illustrate the nature, extent and scope of duties and responsibilities of the classes they describe.  Standards cannot and do not include all of the work that might be appropriately performed by a class.  The minimum qualifications above are those which were required for appointment at the time the Classification Standard was written.  Please contact the Division of Staffing Services for current information on minimum qualification requirements for appointment or examination.