SUPERVISING HEALTH INSURANCE BENEFITS CLERK

Code: 03887@ Local Competitive

Official job specification

The text below is the official specification published by the New Jersey Civil Service Commission. The plain-language summary and analysis above are derived from it by NJ Civil Service Navigator. Source: the official specification page at NJ CSC.

Definition

Under direction, supervises and performs highly responsible work involved in examining and checking insurance policies to determine the extent of coverage; advises claimants of insurance benefits and explains procedures for filing claims; reviews and checks claims to ensure compliance with rules and regulations of the insurance company or of a government agency; has charge of a health insurance benefits unit; does other related duties as required.

Examples of work

• Supervises the processing of claims for one or more private or government insurance plans.
• Supervises the review of insurance policies of claimants to determine policy coverage so that maximum benefits can be obtained.
• Examines claims for medical and health expenses.
• Establishes and certifies validity of claims when required.
• Checks forms for completion and compliance with requirements established by the applicable government agency or insurance company.
• May assist in planning and revising claims processing procedures and office routines.
• Receives, reviews, and adjusts complaints.
• Prepares requisitions.
• Types documents from varied forms of copy.
• Answers inquiries, and guides, instructs, and assigns tasks to staff, and participates in and is responsible for the work of staff.
• Compiles data for budgets and reports.
• Makes special studies of certain operations, and reports findings.
• Prepares correspondence.
• Prepare periodic statements and reports.
• Acts as liaison for claimant, insurance agency, and those from whom information is required.
• Gives advice concerning insurance coverage and benefits.
• Makes decisions requiring knowledge of the organization, rules, and regulations.
• Maintains, classifies, indexes, and cross-references records and files.
• Plans and revises work schedules to meet changes in workload considering factors such as peak loads and human resource availability.
• Coordinates activities with representatives of other units concerning matters of work accomplishment, priorities, and procedures.
• Assigns work to employees and/or assigns employees to positions.
• Assigns tasks as necessary to provide new employees with experience and training required to perform the work.
• Assigns work (including overtime, disagreeable or choice tasks, and so forth) among employees equitably.
• Explains work requirements, methods, and procedures, giving special instructions on difficult or different operations and answering technical questions about the work.
• Informs supervisor of anticipated vacancies, increase in work load,or other circumstances to obtain replacements, temporary help, or additional staff.
• Recommends, informally, promotions, reassignment, or other status changes of assigned personnel such as retention or release of probationary employees, and salary increases, and recognizes outstanding performance by recommending meritorious awards.
• Oversees attendance and leave, typically including approval of ordinary sick, annual leave, and vacation schedules.
• Makes changes in organization of work or assignment of functions to positions to improve work flow and service rendered, promote job satisfaction, and increase productivity.
• Assigns work to employees based on a selective consideration of such factors as difficulty and requirements of assignments, availability, capability, and special qualifications of employees, and other resources availability.
• Formulates and issues (individually or collectively with other supervisors or specialists) written instructions and procedures, and special instructions for nonroutine or complex assignments, or to clarify published guidelines.
• Sets or participates in setting performance standards.
• Prepares formal requests for filling vacancies or for additional personnel to meet workload requirements.
• Selects or participates with considerable weight in the selection of employees from lists of eligibles.
• Prepares formal requests and recommendations for promotions, reassignments, other status changes, or recognition of outstanding performance of assigned employees.
• Receives formal grievances, resolving those that can be resolved.
• Takes disciplinary action as deemed necessary and proposes to higher authority a specific disciplinary action consistent with the problem and facts.
• Formulates training plans for assigned employees.
• Conducts informal training to broaden employee skills and to backup skills by cross-training.
• Recommends more formal training when need is apparent.
• Will be required to learn to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.

Experience

Three (3) years of experience in work involving the determination of insurance, welfare, or social service benefits or services.

License

Appointees will be required to possess a driver's license valid in New Jersey only if the operation of a vehicle, rather than employee mobility, is necessary to perform essential duties of the position.

Knowledge, skills and abilities

• Knowledge of methods, practices, procedures, and regulations involved in processing claims for medical and health insurance.
• Knowledge of medical and insurance terminology.
• Knowledge of office methods, practices, and equipment as they relate to clerical processing of health insurance claims, forms, and bills.
• Ability to type accurately and rapidly.
• Ability to deal effectively and tactfully with people.
• Ability to organize and develop efficient work methods.
• Ability to give assignments and instructions to individuals and groups.
• Ability to supervise the maintenance of records and files.
• Ability to comprehend, analyze, and interpret regulations and procedures.
• Ability to comprehend and interpret data relating to medical diagnosis and prognosis.
• Ability to review and analyze cases to determine adequacy and other related data.
• Ability to prepare clear, sound, accurate, and informative reports pertaining to determination of benefits.
• Ability to learn to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.
• Ability to read, write, speak, understand, and communicate in English sufficiently to perform duties of this position. American Sign Language or Braille may also be considered as acceptable forms of communication.
• Persons with mental or physical disabilities are eligible as long as they can perform the essential functions of the job after reasonable accommodation is made to their known limitations. If the accommodation cannot be made because it would cause the employer undue hardship, such persons may not be eligible.

Note

The examples of work for this title are for illustrative purposes only. A particular position using this title may not perform all duties listed in this job specification. Conversely, all duties performed on the job may not be listed.