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Nature of Work
Under general supervision at the full-performance level,
performs complex technical work reviewing and determining the
compensability of medical claims covered by Workers' Compensation
benefits. The work involves review of confidential data
regarding medical evidence and psychiatric reports which demand
accuracy on the part of the employee to insure that benefits are
awarded in accordance to the statutes and laws governing the
fund. The work requires the employee to review claims in a
timely fashion because of the large volume of medical claims.
Errors in work may result in time-consuming legal actions filed
by claimants or their employers, affecting the immediate work
area and other divisions as well. Performs related work as
required.
Distinguishing Characteristics
This position is characterized by the review of medical
claims to determine the extent of injuries, whether previous
injuries contributed to the current injury, and how debilitating
the injury is according to precedents. The position has
authority to order additional tests and examinations for
claimants prior to determining percentage of disability.
Examples of Work
Reviews medical claims following medical and statutory
guidelines and applies knowledge of medical cause-effect
relations in accident situations to determine
compensability for WCF benefits.
Dispenses claimants' medical reports to employers' attorneys
and claimants to advise them on the nature of the injury
and type and progress of treatment.
Counsels claimants over the telephone or in person regarding
the processing and completion of medical and Occupational
Pneumoconiosis claims.
Authorizes and denies medical expenditures for supplies,
braces, appliances, physical therapy, dental work and other
forms of treatment.
Reviews request for re-opening of claims.
Determines claimants' eligibility for on-going payments of
temporary total disability benefits.
Determines eligibility for Noise Induced Hearing Loss Claims.
Refers claimants to physicians for Permanent Total, and Second
Injury Life Awards examinations.
Knowledge, Skills and Abilities
Knowledge of laws and statutes governing the Workers'
Compensation Fund.
Knowledge of the operation of the Fund.
Knowledge of the medical terminology and anatomy.
Knowledge of medical codes.
Skill in writing communiques and quasi-legal documents.
Ability in developing pertinent facts and evidence related to
claims adjudication.
Ability in determining medical and physiological cause-effect
relations in accidents.
Ability to analyze, interpret and summarize complex medical
data.
Ability to establish and maintain effective relationships with
claimants, physicians, attorneys, public officials and
other personnel.
Minimum Qualifications
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Training:
Education equivalent to graduation from a standard
high school.
Experience:
Six years of full-time or equivalent part-time
paid employment in insurance claims examination dealing
with disability claims or accident and medical records.
Substitution:
Course work from an accredited four-year college
or university, or related business school or vocational
training may substitute through an established formula for
up to four years of the required experienced.
Established: 12/1/91
Title Change: 1/16/09
Effective:
1/16/09