Claims Services Representative 1/Trainee 1/2 - NYHELPS

Claims Services Representative

Under the general supervision of a Claims Services Representative 2 responsibilities include, but are not limited to:

• Oversee all aspects of workers compensation claims processing from inception to closing
• Initially determine the compensability of claims and files appropriate documentation with the Workers Compensation Board (WCB)
• Calculate and adjust reserves consistent with case analysis over the anticipated life of the claim
• Recommend cases for appeal to WCB
• Negotiate and/or make recommendations regarding lump sum settlements
• Issue payments and requests for reimbursement where claims for supplemental benefits are involved
• Review awards to ensure the correct recipient and rate of compensation
• Schedule or waives medical examinations as necessary
• Analyze medical bills to determine causality, levels of treatment, necessity for treatment, appropriateness of fees and procedure codes, and apportionment status
• Respond to requests for home modifications, home health care personnel, medication, and medical supplies and appliances
• Negotiate billing adjustments with medical care providers and suppliers applying workers compensation fee schedules and rules
• Identify and initiates referrals to the Legal Department
• Review case activity and determine when a claim can be retired
• Specific duties to be discussed at time of interview.

Minimum Qualifications:

For appointment via NY HELPs:

• Claims Services Representative Trainee 1: Four years of experience* processing Workers Compensation or Disability Benefits including Paid Family Leave claims.
• Claims Services Representative Trainee 2: Five years of experience* processing Workers Compensation or Disability Benefits including Paid Family Leave claims
• Claims Services Representative 1: Six years* of experience processing Workers Compensation or Disability Benefits including Paid Family Leave claims.

*An associate degree may substitute for two years of experience; a bachelor's degree may substitute for four years of experience; a master's degree may substitute for five years of experience; and a doctorate may substitute for six years of experience.

For competitive appointment:

• Transfer: Current New York State employee with one year of permanent competitive class service in a title eligible for transfer under Section 70.1 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 for transfer to Claims Services Representative Trainee 1 include, but are not limited to: Investigator 1, Assistant Insurance Fund Services Representative, Program Aide. Eligible titles for transfer to Claims Services Representative Trainee 2 include but are not limited to: Administrative Specialist Trainee 2, Claims Services Representative DB Trainee 2, Underwriter Trainee 2. Eligible titles for transfer to Claims Services Representative 1 include, but are not limited to: Administrative Specialist 1, Claims Services Representative 1 DB, Underwriter 1.
• Reinstatement: Candidates who have held the title of Claims Services Representative Trainee 1, Claims Services Representative Trainee 2, or Claims Services Representative 1, 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.

Additional Comments:

For candidates new to NYS, the starting salary for this position will be the bottom of the range displayed and is not subject to negotiation. For candidates that are current NYS employees, salaries are calculated in accordance with NYS Civil Service Law, OSC Payroll rules and regulations, and negotiated union contracts.

Fringe Benefits:

• Competitive compensation
• Future career growth potential
• Open and supportive team-based environment
• Plentiful vacation, personal, and sick time off
• Paid state and federal holidays
• Affordable health insurance plans
• Dental and vision benefits provided at no additional cost
• Retirement options
• Public Student Loan Forgiveness (PSLF)
• Possibility of telecommuting, flextime, and Alternative Work Schedules (AWS)

NY HELPS Program:

This title is part of the New York Hiring for Emergency Limited Placement Statewide Program (NY HELPS).

For the duration of the NY HELPS Program, this title may be filled via a non-competitive appointment, which means no examination is required but all candidates must meet the minimum qualifications of the title for which they apply.

At a future date, it is expected employees hired under NY HELPS will have their non-competitive employment status converted to competitive status, without having to compete in an examination. Employees will then be afforded with all the same rights and privileges of competitive class employees of New York State. While serving permanently in a NY HELPS title, employees may take part in any promotion examination for which they are qualified.

About NYSIF:

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