Tentative Classification Standards issued by the Division of Classification & Compensation are shared with the operating agencies of State government for their consideration and comment. Accordingly, this document that you are viewing is subject to change and will be issued in final form at the completion of the review period.

TENTATIVE

                                                                                               Occ. Code 6812100

 

CLAIMS SERVICES REPRESENTATIVE 1, GRADE 18                                                                                                                                                                                                                              

6812100

CLAIMS SERVICES REPRESENTATIVE 1 (DISABILITY

 BENEFITS), GRADE 18

6812110

CLAIMS SERVICES REPRESENTATIVE 2, GRADE 23

6812200

CLAIMS SERVICES REPRESENTATIVE 2 (DISABILITY

 BENEFITS), GRADE 23

6812210

CLAIMS SERVICES REPRESENTATIVE 3, GRADE 25

6812300

 

 

 

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 including Paid Family Leave claims filed with the New York State Insurance Fund (NYSIF). 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 the New York State Insurance Fund.

DISTINGUISHING CHARACTERISTICS

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

          CLAIMS SERVICES REPRESENTATIVE 1 (DISABILITY BENEFITS): first supervisory level; oversees all aspects of disability benefits claims processing; provides assistance to claimants, medical care providers, and policyholders on 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 2 (DISABILITY BENEFITS): second-level supervisor; assists in overseeing claims processing functions for the Disability Benefits program; handles the most sensitive cases.

          CLAIMS SERVICES REPRESENTATIVE 3: second-level supervisor; 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

          CLAIMS SERVICES REPRESENTATIVE 1:  under the general supervision of a Claims Services Representative 2, oversees all aspects of workers compensation 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 1 (DISABILITY BENEFITS): under the general supervision of the Claims Services Representative 2 (Disability Benefits), oversees a work unit consisting of eight to ten staff members and directs the workflow of the unit in accordance with the policies, procedures, workflows and internal controls; oversees subordinate staff, and intervenes and resolves problems as necessary; determines staff assignments; approves leave, and tracks time and attendance; monitors and evaluates staff performance; completes performance evaluations; identifies training needs and arranges for staff training; and manages and directs program activities by setting priorities and deadlines; provides direction on concurrent employment claims payment determinations when a claimant has two or more employers which will require a determination for partial payment among the two insurance providers by working with subordinates to request, obtain and review the second employers wage verification to determine percentage of the benefit payment; reviews and makes claims decisions in cases where accidents or injuries occur from an illegal act that may arise from self-inflicted incident, drug or alcohol abuse consistent with Disability Benefits Law and the paid Family Leave Benefit Law; when processing overpayments and refunds, reviews the claim and confirms that the payment determination has been calculated correctly by staff before forwarding on to management for processing of the overpayment or refund; and provides assistance to the Claims Services Representative 2 (Disability Benefits) in developing and maintaining policies and procedures to ensure that whenever possible process improvements are identified and recommended to ensure that the claims process is operating efficiently and is appropriately staffed

          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 2 (DISABILITY BENEFITS): under the general supervision of the Director NYSIF Disability Benefits Fund program, oversees the claims activities in the Disability Benefits Program; establishes and oversees a process for approving, rejecting, maintaining, or retiring disability benefits and paid family leave claims; establishes and disseminates policies and procedures to ensure the effective and efficient processing of all claims by the appropriate levels of staff; reviews the claims process to ensure that appropriate internal controls are in place to prohibit processing errors, fraud, failure, and to prevent inconsistent application of processing procedures; annually reviews and reports the status of all program controls reviews, and addresses and documents,  and takes remedial actions on all internal control audit findings; manages the cash management process for claim overpayments and refunds; assists with escalated customer complaints to resolve conflicts with the goal of promoting policyholder retention and claimant satisfaction while processing claims in accordance with all relevant laws, policies and procedures; administers ongoing training to claims staff to keep them informed of New York State Workers Compensation Law Disability Benefits Insurance requirements, NYSIF claims procedures, and electronic system updates which impact the processing of claims; reviews the workflow for claims applicants to ensure timely compliance of the issuance of all claims payments; oversees policyholder requests for business activity reports (BAR) and the timely provision of W-2 tax form information to policyholders and claimants; serves as a lead for initiatives that support systems creation and modernization to provide claims processing capabilities and upgrades which improve internal efficiencies, implement mandatory reporting requirements to comply with Workers Compensation Law, the Workers Compensation Board (WCB), and the Department of Financial Services. (DFS); evaluates rejected claims, provides justification for rejection, serves as a claims resource to Hearing Representatives and coordinates hearing process when notified of scheduled hearings by the New York State Workers Compensation Board; acts as the primary lead on vendor relations and evaluates the costs and benefits from their deliverables;  verifies vendor billing statements to attest to the services provided and communicates discrepancies for resolution before approving payment of services; reviews daily claims inventory within the Claims Units and  identifies situations when unit support is warranted; coordinates with first level supervisors to delegate claims to Assistant Insurance Fund Services Representatives with lower inventory to create partnerships resulting in improved timeliness of claims processing; assesses productivity, reviews accuracy and quality and completeness of the documentation of claim payments while monitoring staffs attention to sound customer service principals in relation to communicating with claimants, health care providers, and policyholder; and ensures that accurate and timely performance feedback is provided to all staff.

          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

          CLAIMS SERVICES REPRESENTATIVE 1

Open Competitive:  bachelors degree and satisfactory completion of a two-year traineeship.

          CLAIMS SERVICES REPRESENTATIVE 1 (DISABILITY BENEFITS)

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.

          CLAIMS SERVICES REPRESENTATIVE 2 (DISABILITY BENEFITS)

Promotion: one year of services as a Claims Services Representative 1 (Disability Benefits).

          CLAIMS SERVICES REPRESENTATIVE 3

Promotion: one year of service as a Claims Services Representative 2.

 

Date:  3/17

 

 

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.