Claims Services Representative 1 / Trainee 1 / 2

Job Description

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; and reviews case activity and determines when a claim can be retired.
Specific duties to be discussed at time of interview.

Minimum Qualifications:
For appointment via NY HELPS:
• To title Claims Services Representative Trainee 1: Four years of experience* processing Workers Compensation or Disability Benefits including Paid Family Leave claims.
• To title Claims Services Representative Trainee 2: Five years of experience* processing Workers Compensation or Disability Benefits including Paid Family Leave claims.
• To journey-level title Claims Services Representative 1: Six years of experience* processing Workers Compensation or Disability Benefits including Paid Family Leave claims.
*Associate degree may substitute for two years of specialized experience; bachelor's degree may substitute for four years of specialized experience.
For competitive appointment:
• List appointment: Reachable on current Civil Service eligible list for this title.
• Transfer: Current New York State employee with one year of permanent competitive class service in a title eligible for transfer under Section 70.1 or Section 52.6 of Civil Service Law. Appointments via transfer must not result in a second, consecutive transfer with an advancement of more than two S-grades or one M-grade. Eligible titles include, but are not limited to: Administrative Specialist 1, Business Systems Analyst 1, Underwriter 1, Policyholder Services Representative 1.
Reinstatement:
• Candidates who have previously held the Claims Services Representative 1 title, or a transferable title, may be eligible for consideration for reinstatement.
For 55b/55c Program appointment:
• This position may be designated 55 b/c and is subject to verification of applicant eligibility. For more information on this program, please visit the 55b/c Recruitment Resources Center.
Please be advised that the New York State Insurance Fund (NYSIF) does not offer sponsorship for employment visas to employees or potential employees. Candidates sponsored for employment by an organization should be aware of their sponsorship status and the relevant expiration date(s) of that sponsorship before applying to this position. NYSIF is not currently enrolled in eVerify, which is a requirement for certain types of employment verifications.

Requirements

For appointment via NY HELPS:
• To title Claims Services Representative Trainee 1: Four years of experience* processing Workers Compensation or Disability Benefits including Paid Family Leave claims.
• To title Claims Services Representative Trainee 2: Five years of experience* processing Workers Compensation or Disability Benefits including Paid Family Leave claims.
• To journey-level title Claims Services Representative 1: Six years of experience* processing Workers Compensation or Disability Benefits including Paid Family Leave claims.
*Associate degree may substitute for two years of specialized experience; bachelor's degree may substitute for four years of specialized experience.
For competitive appointment:
• List appointment: Reachable on current Civil Service eligible list for this title.
• Transfer: Current New York State employee with one year of permanent competitive class service in a title eligible for transfer under Section 70.1 or Section 52.6 of Civil Service Law. Appointments via transfer must not result in a second, consecutive transfer with an advancement of more than two S-grades or one M-grade. Eligible titles include, but are not limited to: Administrative Specialist 1, Business Systems Analyst 1, Underwriter 1, Policyholder Services Representative 1.
Reinstatement:
• Candidates who have previously held the Claims Services Representative 1 title, or a transferable title, may be eligible for consideration for reinstatement.
For 55b/55c Program appointment:
• This position may be designated 55 b/c and is subject to verification of applicant eligibility. For more information on this program, please visit the 55b/c Recruitment Resources Center.
Please be advised that the New York State Insurance Fund (NYSIF) does not offer sponsorship for employment visas to employees or potential employees. Candidates sponsored for employment by an organization should be aware of their sponsorship status and the relevant expiration date(s) of that sponsorship before applying to this position. NYSIF is not currently enrolled in eVerify, which is a requirement for certain types of employment verifications.