CRIME VICTIMS CLAIMS EXAMINER

Idaho Industrial Commission Job Opportunity

The mission of the Crime Victims Compensation Program is to ensure eligible victims are provided appropriate financial assistance to aid in recovery from the traumatic effects of crime.

Applications will be accepted through 11:59 PM MST on the posting end date.

The Industrial Commission is seeking a Crime Victims Claims Examiner in the Boise office. Idaho’s Crime Victims Compensation Claims Examiners review bills as they are received to ensure expenses are crime-related and work with health care providers if additional detail is needed. After the claim is checked, the Examiner will authorize appropriate payment or deny the claim. Our Claims Examiners are intellectually disciplined in applying, analyzing, and evaluating information gathered to determine the validity and compensability of claims received and work strictly within the program’s statutes and guidelines. Examiners excel at communication and are the program’s primary liaison between insurance carriers, providers, and third-party agencies. The ability to work within a service-minded, victim-centered team is critical.

This position requires the ability to deal with violent and sexually explicit crime victim subject matter.

A criminal background check must be completed prior to appointment with the Idaho Industrial Commission.

Example of Duties:

• Reviews medical records, CPT codes, ICD10 coding and compares the documentation to the description of the victim's injuries as related in the law enforcement report to ensure that the claim is compensable under the law.
• Reviews insurance explanation of benefits to verify payment amounts and procedure codes billed.
• Contacts third-party payers for clarification on available benefits.
• Calculates benefits to determine the appropriate amount to be paid to ensure that payment complies with any reduction made in the case or bill and prevent payments from exceeding benefit maximums as defined by law.
• Composes correspondence regarding billing inquiries and benefit maximums.
• Solicits additional information from treatment providers to verify whether treatment is related to injury sustained in a crime that benefits were awarded.
• Authorizes payment, reduction and/or denial of bills after review of all criteria
• Works with Case Managers to identify and resolve treatment issues.
• Monitors on-going treatment and makes recommendations to Case Manager regarding proposed course of action/s.
• Reviews billing patterns for excessive, unnecessary, or unreasonable treatment or fraud.
• Reviews and enters all incoming bills, third-party payments and W9 tax form information into the CV database system.

Minimum Qualifications ; Typically met by at least 6 months in each of the areas identified.

Experience:

• Conducting and documenting in-depth fact-finding interviews, analyzing information and making decisions based on facts
• Interpreting, applying, and explaining laws and regulations related to claims.

Good knowledge of

• ICD10 and CPT codes.
• Composing claims correspondence.
• General insurance terminology and claims handling procedures.
• Interviewing methods.
• Entering and verifying information in a computerized records system.

Some knowledge of:

• Private insurance, public benefits, third-party liability procedures/regulations, and benefits coordination practices.
• Medical and mental health terminology used in the processing of claims.

Ability to Deal with violent and sexually explicit subject matter.

Desirable Qualifications

• Experience conducting and documenting in-depth fact-finding interviews
• Intermediate word processing skills
• Problem-solving and conflict resolution skills

To learn more about the Idaho Industrial Commission, please visit our website.

The State of Idaho is committed to providing equal employment opportunities and prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on their race, color, religion, political affiliation or belief, sex, national origin, genetics, or any other status protected under applicable federal, state, or local laws.

The State of Idaho is committed to access and reasonable accommodations for individuals with disabilities, auxiliary aids and services are available upon request. If you require an accommodation at any step in our recruitment process, you are encouraged to contact (208) 334-2263 (TTY/TTD: 711), or email ada.coordinator@dhr.idaho.gov.

Preference may be given to veterans who qualify under state and federal laws and regulations.