Positions in this job family are assigned responsibilities involving the receipt, review, evaluation and resolution of claims related to workers’ compensation benefits, payments for health, dental or other medical care, or compensation related to life, disability or retirement insurance. This includes review and evaluation of various claims and approval or disapproval of requested benefits as appropriate.
TYPICAL FUNCTIONS
The functions within this job family will vary by level and type of insurance, but may include the following:
Examines and evaluates claims for payment of various worker’s compensation benefits or other benefits under health, dental, life, disability or other insurance programs; approves or denies claims as appropriate; initiates payment actions and makes adjustment to funds reserves as needed.
Investigates claims for compensability, potential subrogation and possible fraud; conducts activity checks and other reviews on permanent injury or death claims or on disputed claims; obtains recorded statements and other evidence; documents results of examination or investigation; requests outside investigations, surveillance or other actions as needed.
Advises medical providers, claimants and others on rules, procedures, policies and laws concerning the insurance program; authorizes or denies medical or dental treatments, surgery, medical equipment, training or other services; requests additional information, medical examinations or other actions.
Authorizes changes in medical providers, medical management, rehabilitative services, vocational training or other procedures or services.
Provides temporary disability payments and monitors case for continuation of benefits; terminates payments when appropriate.
Conducts negotiations for settlement of claims with claimants and attorneys; insures preparation and filing of necessary legal documents.
Prepares reports on claims and loss statistics and other information as required.
KNOWLEDGE, SKILLS, & ABILITIES
Level I: Knowledge of applicable rules, regulations and statutes related to the insurance program for which responsibility is assigned; of methods and procedures used in reviewing and evaluating claims; of procedures for conducting claims investigations; of medical terminology; of treatments for various types of injuries and illnesses; and of modern office procedures. Also required is the ability to review and analyze written information; to communicate effectively; to prepare reports; and to establish and maintain effective working relationships with others.
Level II: Those identified in Level I plus ability to review and analyze a variety of claims concerning payments for injuries, illnesses or other causes.
Level III: Those identified in Level II plus demonstrated ability to review and evaluate a wide range of claims and to perform highly independent work.
Level IV: Those identified in Level III plus knowledge of supervisory principles and practices. Ability to supervise the work of others.
LEVEL DESCRIPTORS
The Insurance Claims Adjuster job family consists of four levels which are distinguished based on the complexity of the work assigned, the level of expertise required to perform assigned duties, and the responsibility assigned for the supervision of others.
Level I : This is the basic level where employees are assigned responsibilities for performing entry-level work. This includes reviewing, evaluating, adjusting, reserving, adjudicating and investigating primarily medical-only claims. The employee will work under close supervision, using established policies and methods. At this level they will have limited authority for final approval or disapproval of requested benefits.
Level II : This is the career level where employees are assigned responsibilities for performing a full range of duties at the full performance level in reviewing and evaluating routine to complex claims, as well as approving payments for medical treatment, training programs or other authorized benefits, setting and adjusting reserves as needed, monitoring and reporting existing and potential claims for exposure in excess of reinsurance retention amounts and/or subrogation, and adjudication of contested and uncontested claims,. Limited responsibility may also be assigned for providing training or assistance to lower level adjusters and/or claims support personnel.
Level III: This is the specialist level of this job family where employees are primarily assigned responsibilties involving the review and evaluations of litigated and non-litigated claims of a complex nature. This includes reviewing, evaluating, adjusting and investigating claims as well as approving payments for medical treatment, training programs or other authorized benefits, setting and adjusting reserves as needed, adjudication of contested and uncontested claims, and monitoring and reporting existing and potential claims for exposure in excess of reinsurance retention amounts and/or subrogation. Employees at this level may be assigned responsibility for training lower level adjusters and for conducting quality control audits to insure compliance with established policies and procedures.
Level IV: This is the leadership level where employees are assigned responsibilities for the supervision of others in reviewing and evaluating claims. This includes reviewing and assigning work, providing training and assistance, and insuring completion of required tasks and activities. Also included are other supervisory responsibilities such as evaluation of performance, employee development, approving leave, recommending disciplinary actions and other administrative responsibilities. Employees at this level will also maintain a claims load ranging from routine to complex claims.
MINIMUM QUALIFICATIONS
Level I: Education and Experience requirements at this level consist of active licensure as a Workers’ Compensation Insurance Adjuster by the Oklahoma Insurance Commission and two years of professional experience in adjusting and reserving casualty insurance claims, one year of which must have been in the adjusting and reserving of Workers’ Compensation claims; or active licensure as a Workers’ Compensation Insurance Adjuster by the Oklahoma Insurance Commission, a bachelor’s degree and one year of experience in adjusting and reserving Workers’ Compensation claims.
Level II: Education and Experience requirements at this level consist of those identified in Level I plus one additional year of professional level experience in adjusting and reserving Worker’s Compensation claims.
Level III: Education and Experience requirements at this level consist of those identified in Level II plus two additional years of professional level experience in adjusting and reserving Workers’ Compensation claims.
Level IV: Education and Experience requirements at this level consist of those identified in Level III, plus two additional years of professional level experience in adjusting and reserving Workers’ Compensation claims.
CLASS: A11A; EST: 8/20/2007; REV: 7/2/2012 7:45:00 AM;
CLASS: A11B; EST: 8/20/2007; REV: 7/2/2012 7:45:00 AM;
CLASS: A11C; EST: 8/20/2007; REV: 7/2/2012 7:45:00 AM;
CLASS: A11D; EST: 8/20/2007; REV: 7/2/2012 7:45:00 AM;
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