PO Box J Prague Oklahoma 74864 405.567.2611 Fax 405. 567.3307
2222 W. Main (Highway 62)
Job Descriptions for Claims Staff
As of January 2006
On January 04, 2006 Elizabeth Miller of County Risk Sharing Authority (Ohio) requested information on job descriptions for claims manager, adjusters, and administrative staff job descriptions. The last two pages of this document contains information on salary, tenure and number of claims handled. Staff reviewed responses from members and included them as follows.
- Janice Shirk, RN, Claims & Medical Manager, Pennsylvania Counties Risk Pool (PCoRP) Page 1
- Lynnette L. McHenry, Assoc. General Counsel & Claims Manager, Page 7
Idaho Counties Risk Management Program (ICRMP)
- Steve Spilde, Chief Executive Officer, North Dakota Insurance Reserve Fund (NDIRF)Page 11
- David Kormann, Executive Director, Page 29
Missouri Public Entity Risk Management Fund (MOPERM)
5.John Smith, Claims Manager, Association County Commissioners of Georgia (ACCG) Page 31
1.Janice Shirk, RN, Claims & Medical Manager, Pennsylvania Counties Risk Pool (PCoRP). –provided job descriptions for Claims and Medical Manager, Insurance Programs Senior Claims Representative, and Claims Administrative Assistant.
Claims and Medical Manager
Job Description: Claims and Medical Manager
The Position: The Claims and Medical Manager is employed by CCAP to provide claims and medical services to the association’s insurance and membership services boards of directors and to members of CCAP Insurance Programs and related member service programs.
The Claims and Medical Manager is part of the management team of the CCAP Insurance Programs Office, performs most work with nominal supervisor, and reports to the Managing Director, Insurance Programs for general direction and work evaluation. The Claims and Medical Manager supervises the employees of the claims unit of CCAP Insurance Programs.
The Claims and Medical Manager is in charge of the CCAP Insurance Programs staff when the Managing Director is not available and cannot be contacted. In these instances, when a major issue or any personnel issue needs to be decided, the Claims and Medical Manager will first consult with the CCAP Executive Director.
Job responsibilities include the selection, installation and operation of a claims management computer system, and design of the positions and duties of the claims unit.
The Claims and Medical Manager also provides support to the general operation of CCAP, including contribution of analyses and other background material for use in the CCAP lobbying effort, and other similar duties.
The Claims and Medical Manager is responsible for supervision of the activities of claims personnel to investigate, process claims, establish reserves and settle claims as authorized, and to render prompt claims service and payment.
The Claims and Medical Manager is the main CCAP staff liaison to the PIMCC Governing Board and the COMCARE Board, and is also involved in any other medical related member service of CCAP.
Claims and Medical Manager
General Responsibilities: The Claims and Medical Manager general responsibilities include:
- Supervision of the claim file handling of adjuster and claims supervisors to insure adherence to claims procedures. Provides guidance on claims, proper reserving and monitors files in litigation.
- Development and continued refinement of claims manual for CCAP Insurance Programs, and training of claims staff in policies and procedures.
- Participation in various contract and insurance policy negotiations.
- Reviews, negotiates, investigates and settles claim files.
- Management of selected workers’ compensation claims.
- Management of selected property/casualty claims.
- Acts as information source for the insurance programs staff, provides information to current members, prospective members, brokers, claims administrators and others concerning regulations, policies, coverage’s and procedures.
- Development and maintenance of a system to store appropriate claims historical information.
- Liaison to COMCARE Board and PIMCC Board and coordinator of services to be provided by CCAP to these programs.
- Management of the litigation performed by legal counsels for insurance program members, in conjunction with the Insurance Programs Legal Counsel.
- Liaison with outside vendors for peer review, utilization review, bill repricing, and other services.
- Preparation of required reports for insurance regulators.
- Preparation of reports for CCAP programs’ boards of directors and committees.
- Assistance with training and educational sessions for program board members and participants.
- Participation in the long range planning for CCAP insurance and member service programs.
- Performance of other assignments and routine business of the association.
- Demonstrated knowledge, skills and abilities in workers’ compensation and property/casualty insurance claims issues, management and analysis.
- Demonstrated knowledge of the Pennsylvania Political Subdivision Tort Claims Act, and experience with the defense of insurance claims filed against the state, counties and/or municipalities.
- Excellent oral and written communication skills, skill and experience in training others, better than average computer skills.
Essential Physical Requirements:
- The essential physical requirements of this position relate to the requirement to be able to operate computer equipment essential to the completion of the position’s responsibilities.
- Periodic travel to CCAP members, insurance agents, board and committee meetings and CCAP workshops and conferences throughout Pennsylvania will be required.
- Periodic travel outside of Pennsylvania, and potentially overseas, for renewal meetings and training conferences.
For purposes of the Fair Labor Standards Act this is an exempt position.
Job Description: Insurance Programs Senior Claims Representative
The Position: The Claims Representative is employed by CCAP to provide claims administration services to the association’s insurance programs.
The Claims Representative is part of the team of the CCAP Insurance Programs Office, performs most work with some supervision, and reports to the Claims and Medical Manager for general direction, settlement authority and work evaluation.
Job responsibilities include the investigation, evaluation, reserving, controlling expenses, monitoring vendors, resolution of claims, and some litigation management.
The Claims Representative also provides support to the general operation of CCAP, including background material for use in the CCAP lobbying effort, and other similar duties.
General Responsibilities: The Claims Representative general responsibilities include; management of workers’ compensation claims (medical only and some lost time).
Claims investigation, evaluation, and resolution.
Recognition of potential excess exposure and prompt reporting to the excess carriers and requesting authority from the Board of Directors.
Acts in conjunction with other members of the claims department as an information source for the insurance programs staff, provides information to current members, brokers, and others concerning coverages, claims status and procedures.
Assistance and participation in training and educational sessions for PCoRP board members , participants and CCAP claims personnel.
Participation in short and long range planning for the CCAP claims unit and for CCAP insurance and member service programs.
Perform tasks as required as back up for Senior Claims Representative and/or Claims and Medical Manager. Performance of other assignments and routine business of the association.
Qualifications: Qualificationsfor the Claim Representative are:
A college degree in business, insurance or related fields and 3 to 5 years experience as a workers’ compensation adjuster. Must have familiarity with computer claims management systems or Windows based programs.
Must demonstrate a knowledge of the Pennsylvania Workers’ Compensation Act.
Good to excellent oral and written communication skills, adequate computer skills.
Theessentialphysical requirements of this position relate to the requirement to be able to operate computer equipment essential to the completion of the position’s responsibilities. Occasional travel to CCAP members, board meetings, committee meetings, CCAP workshops and conferences throughout Pennsylvania will be required.
Possible travel outside of Pennsylvania for training conferences.
For the purposes of the Fair Labor Standards Act this is an exempt position.
Created April 1999
Job Description:Claims Administrative Assistant
The Position: The Claims Administrative Assistant is employed by CCAP to provide claims reporting services for the association’s insurance programs.
The Claims Administrative Assistant is part of the team of the CCAP Insurance Programs Office, performs most work with normal supervision and oversight, and reports to the Claims and Medical Manager for general direction and work evaluation.
Job responsibilities include setting up, refining and monitoring, in conjunction with
the Claims and Medical Manager, the check processing and financial components of the STARS claims management computer program including all financial aspects of the STARS claims computer system and the production of financial and loss reports. The Claims Administrative Assistant also inputs new claims into the STARS system and performs other claims related work as directed, including preparation of mailings and other clerical duties.
The Claims Administrative Assistant also provides support to the general operation of CCAP, including specific projects assigned by the Claims and Medical Manager, and other similar duties.
General Responsibilities: TheClaims Administrative Assistant’s general responsibilities include:
Printing, proofing, obtaining appropriate signatures and mailing all Pcomp, PCoRP and TPA claims checks, in a timely manner based on the parameters established by the CCAP Claims Manual. Matching the Eob’s with the appropriate check and the monitoring of recurring payments. Processing the deductible billings and mailing to the broker and county. Input the deductible payments into STARS under the appropriate claim.
Developing and printing STARS claims systems reports for internal use of CCAP insurance programs staff, including loss information. Process and print the monthly aggregate reports. Process, print and mail the quarterly loss runs to the counties and brokers. Set up and maintain quarterly loss run notebooks for the entire insurance staff. Assist in the process of any adhoc reports requested by insurance staff or brokers. Run reports for and compile the aggregate excess report.
Opening and distributing all daily mail for Pcomp and PCorp adjusters.
Providing back up phone answering for the CCAP insurance programs office.
Copying, collating, and preparing mailings to CCAP members.
Filing, correspondence and other administrative duties.
Performing other assignments and routine business of the association.
Qualifications: Qualifications for the Claims Administrative Assistant
The Claims Administrative Assistant position requires:
A high school diploma, and
1 to 3 years experience.
Must have familiarity with windows software or claims management system.
Excellent oral, written communication, organizational and computer skills.
Essential Physical Requirements:
The essential physical requirements of this position relate to the requirement to be able to operate computer equipment essential to the completion of the position’s responsibilities.
Periodic travel to board meetings, committee meetings, CCAP workshops and conferences throughout Pennsylvania may be required.
For the purpose of the Fair Labor Standards Act this is a nonexempt position.
Created January 2002
Revised November 2004
2.Lynnette L. McHenry, Associate General Counsel & Claims Manager, ICRMP – Provides job descriptions for Claims Assistant, Claims Technician
Reports To:Claims Manager
Definition: Administrative support staff for the claims department along with direct administrative support to the Claims Manager
Basic Job Responsibilities:
- Assist the Claims Manager and claims staff with various secretarial tasks, including computer-generated reports and drafting basic letters.
- Handle and route all calls, mail, emails, faxes and other correspondence for the claims department.
- Handle small first-party claims.
- Setup and distribute claims to all claims staff.
- Pay bills directly associated with claims, print checks and other reports as requested by claims staff and accounting department.
- File and maintain filing system.
- Copy, print photos and other duties as needed by the claims staff.
- Assist claims manager in administrative tasks as requested.
- Provide administrative support to manager and support the claims staff.
- Have experience in administrative and clerical procedures and responsibilities.
- Ability to handle multiple phone lines.
- Ability to communicate effectively with customers, members and co-workers.
- Must have current PC skills.
- Excellent customer service skills.
- Must be a cooperative team player.
- Excellent time management skills and have the ability to prioritize tasks.
- Excellent organizational skills in atmosphere with frequent interruptions.
- Ability to work well under pressure.
- Willingness to attend trainings and other events as requested.
- Willingness to perform other duties and responsibilities as needed.
Reports To: ICRMP Claims Manager
Definition:Manage first- and third-party Auto, Property, General Liability and occasional Law Enforcement and Errors & Omissions claims.
- Claims Investigation:
- Analyze and investigate claims and develop an action plan to facilitate dispositions.
- Correctly determine policy coverage, complete a thorough investigation of the claim and develop a clear understanding of all evidence relating to the claim.
- Claim File Investigation:
- Evaluate and determine the degree of member’s liability or damages, claimant’s damages, and probable defense costs, and then set reserves based on most current information and analysis.
- Prepare and submit claim file reports in a timely manner.
- Review claim files and diaries in a timely manner and keep file notes up-to-date.
- Draft appropriate documents in a professional manner (declination letters, denial letters, claim files reports, etc.).
- Resolution of Claims:
- Aggressively move a claim to either a denial or settlement by creative and proactive file handling.
- Maintain at minimum a 1:1 beginning to closing claim ratio.
- Negotiate settlements within authority limit.
- Arrange and attend settlement conferences, mediations, arbitration hearings and trials as needed.
- Coordinate and direct subrogation and recovery matters.
- Management of Resources:
- Prioritize and organize workload effectively and keep claim diaries current.
- Must demonstrate strong communication and organizational skills.
- Direct and control outside services, including attorneys and independent adjusters.
- Computer Competence:
- Must demonstrate competence in using computer systems and software to accomplish work assignments.
- Teamwork/Customer Service:
- Work effectively with other ICRMP employees and members by being a team player.
- Strong communication skills required along with the ability to keep your composure in stressful situations.
- Excellent writing and verbal communication skills required.
- Must be able to effectively and pleasantly communicate with all ICRMP members.
- Ability to travel on occasion and be willing and able to attend various training sessions.
- Willingness to become proficient in local governmental law.
- Experience with public entity claims helpful but not required.
CLAIMS MANAGER DUTIES
REVIEW THE FOLLOWING:
- Expense reserve – expense paid
- Reserve history dates
- Timely CFRs
- Litigation budget/plans
- Timely contact w/insured & claimant
- Coding: open-litigation; PL v. GL v. EO
- Subrogation possibilities
- Quality of file documentation
- Evaluation clear? Damage value x percentage of loss = reserve
- Plan of Action? W/target dates?
3.Review $100,000+ claims
4.Review 5 years or older DOL claims
5.Spot check small property claims
CLAIMS SPECIALIST DUTIES
Basic Job Responsibilities:
- Analyze and investigate claims and develop an action plan to facilitate dispositions;
- Prepare and submit claim file reports in a timely manner;
- Place adequate reserves on files;
- Maintain close contact with reinsurers, agents and members;
- Direct and control outside services, including attorneys and independent adjusters;
- Participate in resolving coverage issues;
- Negotiate settlements within authority;
- Arrange and attend settlement conferences, mediations, arbitration hearings and trials;
- Provide proper guidance to members;
- Coordinate and direct subrogation and recovery matters;
- Maintain a good working relationship with members;
- Review claim files and diaries in a timely manner and keep file notes up-to-date;
- Attend training seminars as required;
- Draft appropriate documents in a professional manner (declination letters, denial letters, claim files reports, etc.);
- Have knowledge of the Idaho Tort Claims Act and other laws pertaining to governmental liability; and
- Perform other duties as assigned.
3.Steve Spilde, Chief Executive Officer, North Dakota Insurance Reserve Fund (NDIRF), provides the following job descriptions, Claims Manager, Assistant Claims Manager, Outside Claims Adjuster, Inside Claims Adjuster
EXEMPT: YesDEPARTMENT: Claims
LOCATION: Bismarck, ND
REPORTS TO: Chief Executive Officer
PREPARED BY: Incumbent(s), CEODATE: October 1996
1. INTRODUCTION: The incumbent directs, manages, supervises and coordinates the claims processing function for the North Dakota Insurance Reserve Fund (NDIRF). Ensures that all claims are paid or settled in accordance with the goals and objectives of the NDIRF. The incumbent provides the highest caliber of professional advice, staff guidance, and support to the CEO and the NDIRF. This Job Description is not a contract and is subject to change.
2. SUPERVISORY CONTROLS: Work is performed under the supervision of the Chief Executive Officer (CEO). This is accomplished through delegation of authority, individual staff guidance, and expected compliance with established policies. Highly unusual or complicated problems may be referred to the CEO for further guidance or decision. Incumbent is expected to rely on his /her experience, judgment and knowledge to resolve problems.