1 MICHIGAN CIVIL SERVICE COMMISSION JOB SPECIFICATION CLAIMS EXAMINER JOB DESCRIPTION Employees in this job complete and oversee a variety of professional assignments to manage a caseload of workers' compensation claims by reviewing new claims to determine the validity of claims, ascertaining proper filings, identifying the need for further investigations, and following claims through closing or settlement. There are four classifications in this job. Position Code Title Claims Examiner-E This is the entry level. As a trainee, the employee carries out a range of professional claims examiner assignments while learning the methods of the work. Claims Examiner 10 This is the intermediate level. The employee performs an expanding range of professional claims examiner assignments in a developing capacity. Claims Examiner P11 This is the experienced level. The employee performs a full range of professional claims examiner assignments in a full-functioning capacity. Considerable independent judgement is used to make decisions in carrying out assignments that have significant impact on services or programs. Guidelines may be available, but require adaptation or interpretation to determine appropriate courses of action. Position Code Title Claims Examiner-A Claims Examiner 12 This is the advanced level. The employee may function as a lead worker or senior worker. At this level, employees are responsible for overseeing the work assignments of other professionals or have regular assignments which have been recognized by Civil Service as having significantly greater complexity than those assigned at the experienced level. NOTE: Employees generally progress through this series to the experienced level based on satisfactory performance and possession of the required experience. JOB DUTIES NOTE: The job duties listed are typical examples of the work performed by positions in this job classification. Not all duties assigned to every
2 PAGE NO. 2 position are included, nor is it expected that all positions will be assigned every duty. Contacts the insured to verify and complete the claim report, and obtains information necessary to properly act upon the claim. Contacts the claimant for description of injury and other pertinent information, and maintains appropriate written records of statements and facts relating to the claims. Obtains relevant medical records and statements from the treating physician. Accepts or denies payment of assigned claims within the requirements of the Workers' Compensation Act, and may make referrals to outside field investigators for further review including activity checks and surveillance. Monitors on-going medical treatment for progress and refers claimants for independent medical evaluation as may be required. Reviews medical bills for excesses, and refers claimant for vocational rehabilitation. Reviews new claims to determine validity and ascertain proper filing, and diaries file for timeliness of processing. Responds to inquiries and complaints related to claims from claimants, attorneys, employers and agents. Ensures file is kept current to reflect all appropriate forms, statements, reports, and monitors file to makes judgement on the continuation of disability. Attends mediation, rehabilitation and advance payment hearings. Sets reserves appropriate for the claim, monitors and adjusts reserve as needed. Maintains on-going file management and review for all assigned cases. Maintains records and prepares reports and correspondence related to the work. Performs related work as assigned. Additional Job Duties Claims Examiner 12 (Lead Worker) Oversees the work of professional staff by making and reviewing work assignments, establishing priorities, coordinating activities, and resolving related work problems.
3 PAGE NO. 3 Claims Examiner 12 (Senior Worker) Performs on a regular basis professional claims examiner assignments which are recognized by Civil Service as more complex than those assigned at the experienced level. JOB QUALIFICATIONS Knowledge, Skills, and Abilities NOTE: Some knowledge in the area listed is required at the entry level, developing knowledge is required at the intermediate level, considerable knowledge is required at the experienced level, and thorough knowledge is required at the advanced level. Knowledge of the principles and practices of insurance claims examination. Knowledge of the collection and interpretation of data. Knowledge of the Workers' Compensation Act and its rules, regulations, forms and procedures. Knowledge of interviewing techniques. Knowledge of medical terminology and treatment procedures. Ability to interpret and apply laws, rules and regulations. Ability to obtain and utilize sensitive information discreetly and objectively. Ability to conduct investigative interviews. Ability to maintain records, prepare reports and conduct correspondence related to the work. Ability to communicate effectively with others. Ability to maintain favorable public relations. Additional Knowledge, Skills, and Abilities Claims Examiner 12 (Lead Worker) Ability to organize and coordinate the work of others. Ability to set priorities and assign work to other professionals. Working Conditions
4 PAGE NO. 4 Physical Requirements Education Possession of a bachelor's degree with a major in business administration, insurance, or in a health-related field such as nursing, physician assistant, or pharmacy. Experience No specific type or amount is required. Claims Examiner 10 One year of professional experience processing, reviewing and making determinations regarding medical insurance claims equivalent to a. Claims Examiner P11 Two years of professional experience processing, reviewing and making determinations regarding medical insurance claims equivalent to a Claims Examiner, including one year equivalent to a Claims Examiner 10. Claims Examiner 12 Three years of professional experience processing, reviewing and making determinations regarding medical insurance claims equivalent to a Claims Examiner, including one year equivalent to a Claims Examiner P11. Alternate Education and Experience Educational level typically acquired through completion of high school and four years of experience in a Departmental Technician position reviewing and evaluating medical and compensation claims may be substituted for the education and experience requirements. Special Requirements, Licenses, and Certifications NOTE: Equivalent combinations of education and experience that provide the required knowledge, skills, and abilities will be evaluated on an individual basis.
5 PAGE NO. 5 JOB CODE, POSITION TITLES AND CODES, AND COMPENSATION INFORMATION Job Code CLAIMEXM Job Code Description Claims Examiner Position Title Position Code Pay Schedule Claims Examiner-E CLAMEXME NERE-174 Claims Examiner-A CLAMEXMA NERE-180 ECP Group 2 Revised 6/1/06 TeamLeaders
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