Employees in this class assist in supporting consumer service, licensure, claims examining, and claims adjusting work related to unemployment insurance, workers’ compensation or other insurance administered or regulated by the state.
This is an entry-level class which functions under direct supervision. Once learned, work may be performed independently and involve both recurring duties and new assignments. Employees in this class refer more complex questions or problems and issues needing direct contact with regulated entities to higher level staff.
Answers questions or complaints from consumers involving personal and commercial property and casualty, life, accident and health insurance, or agent, adjuster, bail bondsmen, collection agency, etc. licensing requirements and status. Serves as dedicated customer service representative responsible for answering inbound calls from claimants, employers, and other stakeholders regarding related inquiries. Takes notices of loss and verifies insurance coverage. Applies policy coverage to determine payments. Assists in reviewing and evaluating personal, casualty, and property claims which include worker's compensation, automobile physical damage, and general liability. Researches, determines applicability, and explains state and federal statutes/regulations and how they apply. Researches and explains policy contract language. Requests medical reports and bills from treating physicians. Reviews medical reports and statements and verifies that items billed are related to the claim. Requests estimates and invoices from claimants and vendors and reviews same to verify that documents received substantiate claim. Requests and reviews police reports. Maintains contact with injured employees and physicians involved in worker's compensation claims. Contacts treating physicians and/or arranges for independent medical examination of claimant. Advises claimants of full benefits and limit on claims, methods of attaining same, and direction of responsibility of parties concerned. Assists in investigations on claims and acquires pertinent information to substantiate claim. Maintains ongoing contact with assigned future medical claimants, their caregivers, vendors, and health care providers. Requests medical reports and bills from treating health care providers. Reviews medical reports and claim information to verify bill submitted relates to medical malpractice claim and all necessary documentation has been received. Processes requests for payment of related charges after determining if fees are reasonable and customary and disallowing unrelated or unnecessary charges after review of suggested cuts by senior examiner.
Knowledge of South Carolina laws and regulations. Knowledge of medical and insurance terminology. Knowledge of office practices, procedures, and equipment. Ability to analyze and draw valid conclusions from documentary evidence.
A high school diploma and work experience that is directly related to the area of employment. A bachelor's degree may be substituted for the related work experience.