State of Connecticut Executive Branch

DEPARTMENT OF SOCIAL SERVICES AND OFFICE OF THE TREASURER: This class is accountable for performing the most complex tasks related to the examination of claims and supporting documentation for validity, legality and subsequent approval for payment.

OFFICES OF POLICY AND MANAGEMENT [INTERGOVERNMENTAL RELATIONS DIVISION] AND STATE COMPTROLLER: This class is accountable for acting as a working supervisor for Claims Examiners engaged in examining claims and supporting documentation for validity, legality and subsequent approval for payment.

DEPARTMENT OF SOCIAL SERVICES:

• Performs specialized duties relating to examination of claims for convalescent care benefits;
• Ensures Medicaid is payor of last resort by reviewing client coverage for Medicare or private health insurance submitted by providers;
• Determines correct payment authorization by applying knowledge of agency policy, state statute and federal regulations;
• Determines proper payment authorization date by identifying third party payment amounts and coverage dates and applying these to benefit claims;
• Reconciles suspect duplicate claims identified by payment contractor and approves correct payment and/or initiates recovery of inappropriately paid claim;
• Analyzes Medicare reconsideration listings or reversals received from Third Party Liability unit to determine proper payment authorization or recovery;
• Acts as liaison for assigned facility for payments processing and recovery;
• Provides training for facility staff regarding payment authorization requirements and policies;
• Documents overpayments through review of various records and reports and determination of correct benefit periods;
• Initiates recovery of Medicaid benefits for claims paid prior to application of other available medical coverage;
• Receives and responds to high volume of telephone calls and written correspondence regarding billing problems, denied claims and other issues from a variety of individuals;
• Performs related duties as required.

• Plans unit workflow and determines priorities;
• Schedules, assigns, oversees, and reviews work; 
• Establishes and maintains unit procedures;
• Provides staff training and assistance;
• Conducts or assists in conducting performance evaluations;
• Acts as liaison with operating units, agencies and outside officials regarding unit policies and procedures;
• Performs a full range of liability and expenditure audits of the State of Connecticut with emphasis on most complex audit requirements;
• Coordinates and monitors work of employees performing audit of liabilities and expenditures for validity, legality and propriety;
• Attends meetings with state agencies regarding audit items;
• Advises and instructs state on liability and expenditure matters;
• Prepares analytical and audit reports; 
• Provides information to Auditors of Public Accounts as necessary;
• Trains new Claims Examiners as necessary;
• May make recommendations on polices or standards;
• May prepare reports and correspondence;
• Performs related duties as required.

• Performs specialized duties related to examination of claims for purposes of returning people to work, negotiating settlements and uncovering fraud;
• Develops or assists in development of indemnity and medical reserves as well as reserve reassessment based upon new information or a change in circumstance;
• Develops and implements claim file action plan by interpreting medical reports and utilizing in-house and outside resources including but not limited to independent medical evaluations, surveillance, Attorney General referral and/or vocational assistance;
• Identifies and resolves disputed issues pursuant to Connecticut General Statute Chapter 568;
• Prepares for and attends Workers Compensation hearings as needed;
• Performs related duties as required.

• Knowledge of
  • relevant state laws and regulations;
  • auditing and record keeping procedures;
  • reserving techniques;
• Skills
  • interpersonal skills;
  • oral and written communication skills;
  • negotiation skills;
  • analytical skills;
  • performing arithmetical computations skills;
• Ability to
  • read, understand and apply laws and regulations;
  • examine and analyze highly complex claims;
  • schedule and prioritize workflow;
  • operate office equipment;
  • operate office suite software;
• Supervisory ability.

Five (5) years of experience in highly complex clerical work involving financial record keeping, auditing, accounting, purchasing or claim processing.

NOTE: For state employees this experience is interpreted at the level of Financial Clerk.

One (1) year of the General Experience must have included accounts payable and/or claims auditing.

• College training may be substituted for the General Experience on the basis of fifteen (15) semester hours equalling one-half (1/2) year of experience to a maximum of four (4) years for a Bachelor's degree.
• One (1) year as a Claims Examiner may be substituted for the General and Special Experience.
• Possession of a current State of Connecticut Workers Compensation Casualty Adjuster License may be substituted for one (1) year of the General Experience.