Associate Claims Examiner

Why You Should Join Us
The State of Connecticut, Department of Social Services (DSS) offers a great chance to grow and develop professionally. As an Associate Claims Examiner, you'll help make sure nursing homes receive payment on time, making a direct impact on Medicaid clients and their families. This position is special because you'll work in a team that values and appreciates your contributions. Join us and be part of a dedicated team that aims for excellent service.

As an Associate Claims Examiner, you will be responsible for:

• Making sure nursing homes have applied all Medicare and/or insurance benefits before authorizing payment on the ImpaCT system.
• Managing the timely payment process to nursing homes once Medicaid becomes the primary payer.
• Identifying and recovering Medicaid payments due to additional Medicare or insurance coverage.
• Responding to written and telephone inquiries regarding eligibility, authorization, and claims payment.
• Attending meetings with nursing homes to discuss payment or recovery issues.
• Collaborating with the Convalescent Accounting Unit staff to ensure outstanding service and support to our clients.

To be successful in this role, you must have:

• Proven experience in claims examination or a related field.
• Strong understanding of Medicare, Medicaid, and insurance benefits.
• Outstanding communication skills, both written and verbal.
• Ability to strictly adhere to policies and procedures.
• Diligent approach with a focus on accuracy and efficiency.
• Ability to work collaboratively in a team-oriented environment.
• Strong problem-solving skills and the ability to determine effective solutions.

We are looking for candidates who are ambitious and eager to contribute to our mission of providing flawless service to our community. If you have a passion for helping others and a dedication to excellence, we encourage you to apply.

What We Offer

• Competitive salary and benefits package.
• Opportunities for professional growth and development.
• An inclusive and empowering work environment.
• The chance to define a meaningful impact on the lives of Medicaid clients and their families.
• Visit our new State Employee Benefits Overview page!
• Work for a Forbes top company: 'Forbes' State of Connecticut Ranked One of the Best Employers of 2023 - State of CT Receives National Recognition for Offering Job Growth, Competitive Benefits, and Flexible Schedule.

If you are ready to take on this exciting challenge and become a valued member of our team, we want to hear from you!

• Please visit our 'Applicant Tips on How to Apply' page or view our tutorial. 
• The minimum experience and training requirements must be met by the close date on the job opening, unless otherwise specified. 
• Although applicants will receive correspondence via email, as a backup they are also encouraged to sign on to their Personal Status Board on a daily basis to monitor their status, view all emailed notices and complete tasks required in the recruitment process.  
• In order to comply with Public Act 21-69, the State of Connecticut is no longer asking for resumes during the initial application process.   
• This posting may require completion of additional referral questions (RQs). You can access these RQs via an email that will be sent to you after the posting's closing date or by visiting your JobAps Personal Status Board (Certification Questionnaires section). Your responses to these RQs must be submitted by the question's expiration date. Please regularly check your email and JobAps Personal Status Board for notifications. Please check your SPAM and/or Junk folders on a daily basis in the event an email provider places auto-notification emails in a user's spam.  
• Note:  At any point during the recruitment process, applicants may be required to submit additional documentation which support their qualification(s) for this position.  These documents may include:  a cover letter, resume, transcripts, diplomas, performance reviews, attendance records, supervisory references, licensure, etc., at the discretion of the hiring agency.  Applicants must meet the minimum qualifications as indicated to apply for this position.  
• Should you have questions pertaining to this recruitment, please contact Liz Pinette at elizabeth.pinette@ct.gov.
• This position will be filled in accordance with contractual language, reemployment, SEBAC, transfer, promotion and merit employment rules. 
• The immediate vacancy is listed above, however, applications to this recruitment may be used for future vacancies in this job class. 
• All application materials must be received by the recruiting agency by the time specified on the job opening for the position for which you are applying. Late applications may not be submitted and will not be considered. Exceptions are rare and limited to documented events that incapacitate a candidate during the entire duration of the job posting time period.  It is the candidate’s obligation and responsibility to request an exception and provide a legally recognized justification to accommodate such exception.  Requests should be made to DAS.SHRM@ct.gov. 
• For current state employees, salary calculations are not necessarily comparable from one of the three branches of state government (i.e., Executive, Legislative, Judicial) to the other.
• Read through this helpful link to prepare for your interview.

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.

OFFICES OF POLICY AND MANAGEMENT [INTERGOVERNMENTAL RELATIONS DIVISION] AND STATE COMPTROLLER:

• 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.

OFFICE OF THE TREASURER:

• 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.

• Experience scheduling and prioritizing workflow to meet deadlines and optimize productivity.
• Experience operating a range of office equipment, including printers, copiers, and fax machines, ensuring minimal downtime.
• Experience using Microsoft Office suite (Word, Excel, PowerPoint, Outlook) to create documents, manage spreadsheets, and communicate effectively.
• Experience demonstrating strong communication skills by conveying information clearly in both verbal and written formats.

AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER

The State of Connecticut is an equal opportunity/affirmative action employer and strongly encourages the applications of women, minorities, and persons with disabilities.

As defined by Sec. 5-196 of the Connecticut General Statutes, a job class is a position or group of positions that share general characteristics and are categorized under a single title for administrative purposes.  As such, a job class is not meant to be all-inclusive of every task and/or responsibility.