Insurance Program Specialist - 00543

WORK EXAMPLES

Assists supervisor by instructing employees, answering questions and distributing, balancing and checking work; may make suggestions on appointments, promotions, performance and reassignments.

Administers the External Review (ER) program by investigating consumer complaints over health insurance claims for traditional insurance plans and for self-funded health benefit plans in the areas of medical necessity, denial for experimental procedures and other adverse health claim determinations.

Processes Independent Review (IR) requests for long-term care insurance determinations; determines eligibility requirements for all ER/IR requests; and communicates with consumers regarding eligibility for ER/IR programs.

Communicates with insurance carriers on legal requirements of the ER/IR programs and monitors all communications with the carriers and independent review organizations for compliance with timelines.

Monitors the contractual relationship between the Iowa Insurance Division (IID) and the University of Iowa to determine whether independent review organizations possess proper legal credentials.

Monitors trends in federal and state health care law; recommends changes, updates or improvements in ER and IR programs; and develops and maintains a current procedure manual for ER/IR programs.

Investigates tort claims by reviewing written reports, contacting agency personnel involved or those most knowledgeable of the facts, or contacting outside authorities or experts. Interviews claimants and/or witnesses; assembles all the information and prepares a report of investigation for the Tort Claims Division of the Attorney General's Office.

Develops and maintains a comprehensive insurance protection program by reviewing and analyzing policies, riders, and endorsements to ascertain the proper insurance coverage.

Sets up specifications for the various types of insurance desired including limits of coverage.

Confers and corresponds with insurance company representatives, employees, and the general public on insurance problems.

Reviews and approves computation of workers' compensation rates and monetary benefits on complex cases to ensure proper disposition.

Reviews and investigates written, telephonic and on-line consumer complaints and inquiries regarding ER/IR programs, insurance carriers, independent review organizations, surveys, and research entities.

COMPETENCIES REQUIRED

Knowledge of federal and state insurance programs, including the Patient Protection and Accountable Care Act (PPACA) and the state law for External Review (ER) and Independent Review (IR) Programs.

Knowledge of insurance claims investigation and adjusting practices.

Knowledge of insurance coverages available and the proper methods of application.

Knowledge of legal terminology.

Knowledge of the social, economic, and labor conditions affecting the Workers' Compensation system.

Knowledge of the Iowa Workers' Compensation Act and national developments relative to Workers’ Compensation programs.

Knowledge of casualty insurance claims adjusting practices.

Ability to deal courteously and tactfully with officials in the public and private sectors, and with claimants.

Ability to interpret rules, regulations, policies and procedures and determine eligibility requirements for all External Review and Independent Review requests.

Ability to coordinate and oversee the work of others, as required.

Ability to interpret and originate rules, regulations, policies and procedures.

Ability to adapt investigative methods and techniques to specific situations.

Ability to observe and record facts clearly and accurately.

Ability to acquire a knowledge of the Iowa Code as it pertains to insurance contracts and the laws governing the operation of insurers.

Ability to analyze and interpret insurance policy language in detail to determine the extent of coverage, the specified exclusions, and the conditions affecting the payment of claims.

Ability to interpret and apply sections of the Iowa Code that pertain to the business operation of insurers, insurance contract requirements, and the obligation of insurers to pay claims, to various types of insurance policies.

Ability to use computers, hardware, and software to enter data, arrange data in meaningful and logical order, to write and lay out materials and presentations.

Displays high standards of ethical conduct. Refrains from dishonest behavior.

Works and communicates with all clients and customers providing quality professional service.

Displays a high level of initiative, effort and attention to detail and commitment by completing assignments efficiently with minimal supervision.

Follows policy, cooperates with supervisors and aligns behavior with the goals of the organization.

Fosters and facilitates cooperation, pride, trust, group identity and team spirit throughout the organization.

Exchanges information with individuals or groups effectively by listening and responding appropriately.

EDUCATION, EXPERIENCE, AND SPECIAL REQUIREMENTS

Graduation from an accredited college or university with a Bachelor’s Degree and four years of work experience in the area of health insurance claims, multi line insurance adjusting, policy development, underwriting, or investigation of insurance claims resulting from accidents;

four years of insurance experience in the area of casualty claims, of which two years must have included experience handling workers' compensation claims; thirty semester hours of college coursework may substitute for one year of the casualty claims experience only with a maximum substitution of two years;

graduation from an accredited school of law;

a combination of education and experience totaling three years in the capacity of a paralegal/legal assistant with emphasis in casualty claims, tort claims, litigation, or workers' compensation, of which at least one year must have been in a formal education program for paralegal or legal assistant.

SELECTIVE CERTIFICATION

For certain designated positions, the Appointing Authority, with Iowa Department of Administrative Services – Human Resources Enterprise approval, may selectively request those applicants possessing a minimum of 12 semester hours of education or 6 months of experience or a combination thereof in one of the following areas:

359 life and health insurance

521 paralegal/legal assistant

533 property/casualty insurance

767 worker compensation claims

Applicants desiring to be considered for these positions should be sure to list applicable coursework and experience on the application.

SPECIAL NOTE:

Incumbents in these positions may be required to travel and stay out overnight. Incumbents will be required to make arrangements on their own regarding transportation to and from assigned work areas. Some out of state travel may be required as assigned by the agency of employment.

Effective Date: 2/12 BR