Occ. Code 2502200
ASSISTANT INSURANCE FUND SERVICES REPRESENTATIVE, GRADE 11
New York State Department of Civil Service
BRIEF DESCRIPTION OF CLASS
The Assistant Insurance Fund Services Representative assists higher level Underwriting or Claims professional staff by processing transactions in the Workers Compensation (WC) or Disability Benefits Fund (DB) programs. These positions process routine new policies and policy renewals; assist in the provision of routine underwriting policy processing activities; or review, process, and pay routine insurance claims.
These positions exist only at the New York State Insurance Fund (NYSIF).
ASSISTANT INSURANCE FUND SERVICES REPRESENTATIVE: entry level; processes the more routine workers compensation or disability benefits claims, new policies or policy renewals, and any routine underwriting policy activities.
Tasks will vary based on whether the individual is assigned to the processing of claims or underwriting activities for the New York State Insurance Funds Workers Compensation program or Disability Benefits program, including Paid Family Leave (PFL) Benefits.
Workers Compensation Claims
An incumbent performs claims activities in the Workers Compensation program, within authority ranges for estimates and settlements promulgated by the Director of Claims Medical, for a variety of claims functions.
Gathers pertinent information, reviews and processes less complex workers compensation claims; and analyzes and processes the payment of medical, compensation, and awards for lower exposure compensation claims by initiating proper processing routines as supported by the medical and employment facts contained in the claims file.
Compiles, maintains and organizes electronic claims files.
Negotiates adjustments or recommends arbitration.
Examines accident and medical reports to determine compensability and liability, seeking guidance and medical expertise as needed if complex medical issues arise.
Manages medical activity on file such as nurse review and involvement, and scheduling medical examinations, when appropriate.
Recommends investigation of cases, as needed, and prepares cases for hearings.
Examines medical bills, authorizes payment and reviews and extends authorization for appropriate medical treatment based upon the medical facts contained in the file.
Gathers supporting information and evaluates Section 32 settlement potential; seeks supervisory review and approval of the settlement, and processes the settlement and closure of the claim, as appropriate.
Complies with appropriate form submission requirements and filing deadlines pursuant to applicable laws and regulations and New York State Workers Compensation Board processes and procedures governing workers compensation claims cases.
Assesses the initial and subsequent reserve estimates based upon the facts contained in the file for medical bills and compensation in consultation with supervisory staff.
Assesses subrogation recovery potential and pursues accordingly.
Responds to written and telephone inquiries from claimants, attorneys, doctors, vendors and employers relative to files assigned or team members files in their absence.
Closes files, as appropriate, within prescribed timeframes as determined by performance measures.
Manages early return to work initiative in cooperation with policyholders, claimants, and physicians.
Works with policyholder services to satisfy policyholder inquiries as to file status and reserve rationale.
Assists higher level claims staff on more difficult and higher valued claims.
Disability Benefits Claims Services
An incumbent performs a variety of Disability Benefits and Paid Family Leave claims activities.
Maintains claims caseload for specified policyholders and employers providing various services throughout the life of a Disability Benefits and Paid Family Leave claim; reviews claims for accuracy and completeness and determines whether additional information is required; and accurately enters claims in systems, efficiently enough to maintain caseload.
Works together with policyholder to qualify the employee/claimant.
Communicates with claimants, policyholders and medical providers to gather information needed to process claims.
Conducts research to cross check current, existing, or past claims payments being provided to the claimant to ensure no duplicate payments.
Determines the appropriate rate of benefit payments; scans and verifies payroll reports; and makes timely, accurate payments on claims and systematically maintains a claims diary.
Processes the FICA worksheet.
Provides any additional information required to assist the Audit and Review (A&R) Departments review, as prior to initial payment all claims are subject to a review by Audit and Review.
Manages follow up for updated medical information for claims greater than 6 weeks.
When needed, initiates the process to stop payment of check prior to issuance in order to allow for the amendment or cancellation of payment.
Develops an understanding of the NYS Workers Compensation Law Disability Benefits Law and the Paid Family Leave Benefits Law, Article 9, Sections 200-242 as it pertains to claims processing for Disability Benefits and Paid Family Leave claims, as well as establishing a comprehensive knowledge of the resources available to resolve issues and answer questions about the statute.
Keeps complete records regarding claims utilizing internal systems such as DocMan, eFile, and case notes.
Prepares information for and schedules New York State Workers Compensation Board, Disability Benefits and Paid Family Leave hearings for NYSIF claimants whose applications for benefits were rejected by NYSIF and are appealing this decision.
Processes mail and responds to webmail and other inquiries; and provides customer service to all claimants, policyholders, medical providers and brokers responding in a timely manner to all claims inquiries from any source including telephone, email, letter and web inquiry.
Workers Compensation Underwriting
An incumbent provides policy processing assistance on all workers compensation underwriting matters which do not require the evaluation of risk, involve large premium policies, or those with sensitive or potentially costly underwriting issues.
Reviews applications for completeness and searching applications for Workers Compensation Law Section 93 issues. This entails conducting extensive research to ensure that neither the business nor the owners have outstanding unpaid premiums (ensures that all past bills are paid in full).
Performs policy search for request to add additional entities; reviews payroll reports and simple audits; and checks the Workers Compensation Board database to verify subcontractor coverage.
Modifies policy coverage through issuance and updates of endorsements.
Issues and voids certificates of insurance.
Processes policies for cancellation and reinstatement within Underwriting guidelines. Ensures timely dissemination of notices regarding insurance against cancellation to aid retention efforts. Processes policy record work (add and delete locations and entities) and documents underwriting file.
Reviews claims to determine if coverage is in accordance with policy contract and underwriting endorsements.
Interacts with current policyholders and representatives to discuss coverage and premium billing inquiries. Responds to general policyholder inquiries including:
- Interviews prospective policyholders and their representatives concerning routine questions on coverage, billing and new workers compensation insurance requests;
- Interacts with current policyholders or their representatives to discuss coverage and premium billing inquiries; and
- Handles requests regarding renewals which do not require complex analysis of risk.
Updates efile and memo as directed by underwriters.
Provides customer service by directing policyholders and representatives to self-serve online; and responds to customer inquiries when new applications are rejected or when new coverage is issued.
Disability Benefits Underwriting
An incumbent provides policy processing assistance for the underwriting activities for the Disability Benefits Program including Paid Family Leave Benefits. This function may include a variety of tasks that support the underwriting function but do not require the independent assessment of risk, critical decision-making, or final determination of insurability.
Processes new routine business applications for the Disability Benefits and Paid Family Leave Insurance.
Reviews applications for completeness; processes standard renewal policies; and rates and codes policies.
Enters and maintains policy information (e.g., amends additional employer locations to non-primary, makes changes in address and contact information, and adds a DBA notation to the policy records).
Issues policies, some of these policies may require prior determinations from higher level staff to assess risk, make critical decisions and determine insurability.
May handle the complete underwriting process for simple policies.
Processes premium quotes for small policies (less than 15 employees); processes small premium payroll reports; provides loss history to small premium policyholders; and creates policyholder certificates.
Files Certified Mail receipts retuned from the U.S. Postal Service for notification to cancelled policyholders; reviews returned mail from the U.S. Postal Service and reaches out to the policyholder to correct the address and contact information; and files electronic faxes into the pending workload folders.
Responds to general policyholder inquiries, and maintains policy files; contacts high premium policyholders in non-payment cancellation to encourage payment for policyholder retention and compliance of coverage; and contacts high premium quote recipients to follow up with information to encourage them to apply for Disability Benefits and Paid Family Leave Insurance.
Open Competitive: four years of customer service experience, one year of which
must have been in an insurance industry setting.
Substitution: an associates degree or higher may be substituted 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.
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.