STATE CLASSIFICATION JOB DESCRIPTION


Salary Group B18

Class No. 2923

CLAIMS EXAMINER III

GENERAL DESCRIPTION

Performs highly complex (senior-level) disability determination or workers’ compensation work.  Work involves coordinating the research and review of claims and case histories, evaluating data, conducting investigations, and preparing case determinations.  May supervise the work of others.  Works under limited supervision, with considerable latitude for the use of initiative and independent judgment.

EXAMPLES OF WORK PERFORMED

Coordinates the research and review of disability or workers’ compensation claims to determine jurisdiction and to secure proper documentation.

Reviews requests for appeal actions, evaluates available material, secures necessary evidence, prepares supporting documentation, and reviews determinations and affirms or revises as needed. 

Arranges for consultative examinations to develop sufficient evidence to adjudicate claims and obtains medical or vocational reviews of evidence.

Assesses individuals’ residual functional capacity and ability to perform past relevant work as a result of alleged impairments. 

Develops physical or mental developmental assessments.

Develops and conducts presentations.

Participates and consults in the program planning process.

Identifies, reviews, and reports cases involving potential fraud.

Represents the State of Texas in administrative hearings regarding workers’ compensation.

May serve as a subject matter expert on claims administration.

May order consultative examinations to investigate undocumented claims and/or clarify medical evidence.

May develop policies and procedures.

May supervise the work of others.

Performs related work as assigned.

GENERAL QUALIFICATION GUIDELINES

Experience and Education

Experience in disability determination, workers’ compensation, or insurance.  Graduation from an accredited four-year college or university with major coursework in business, social work, or a related field is generally preferred.  Experience and education may be substituted for one another.

Knowledge, Skills, and Abilities

Knowledge of applicable laws and regulations concerning disability determination or workers’ compensation, and of medical and psychological terminology.

Skill in customer service techniques, and in the use of a computer and office equipment.

Ability to prepare determinations or claims explanations, to apply and explain relevant laws, to read and analyze documents, to prepare correspondence, to manage caseloads, to communicate effectively, and to supervise the work of others.


State Auditor’s Office

Revised 9-1-15