INSURANCE EXAMINER II - 43003112

State of Florida•TALLAHASSEE, FL

2d•$52,000 - $82,876•Onsite

About The Position

This is work conducting on-site field audits, desk audits, and re-audits of insurers to ensure proper practices relating to workers’ compensation claims handling procedures and monitoring the business practices of insurance companies to ensure their compliance with the workers’ compensation law and administrative rules. The Insurance Examiner II is responsible for the analysis, examination and/or investigation of patterns and practices of unreasonable delay in claims handling; timeliness and accuracy of payments to injured workers and reports under sections 440.13, 440.16, 440.185, and 440.20, Florida Statutes (F.S.), and Rules 69L-3 and 69L-56, Florida Administrative Code (F.A.C.). The Insurance Examiner II is also responsible for identifying patterns and practices of harassment, coercion or intimidation of claimants as defined by Chapter 440.525(2), F.S.; ensuring compliance with medical services billing, filing and reporting under Rule 69L-7.710, F.A.C. The Insurance Examiner II assists the Workers’ Compensation Administrator and Government Consultant II in conferring with insurance company personnel and management regarding practices or possible violations of the Workers’ Compensation Law and determines penalties as required. Monitors performance of individual insurers as required by Chapter 440, F.S. and Division Rules, using Division data systems. The Insurance Examiner II uses systems data reviews to determine timely payments of compensation to injured workers and timely filing of forms in compliance with Florida Statutes and Division Rules. Investigates complaints assigned by the Workers’ Compensation Administrator relating to claims administrators who are non-compliant. All parties of the specific claims administrators are contacted in an attempt to resolve the issue as well as any other existing problems. Any issues that are determined to be in violation of the workers’ compensation law are documented and all parties are notified. The Insurance Examiner II continues to monitor all complaints to determine if a trend exists representing deficient claim administrator practices. Investigates denied cases to determine questionable claims handling practices by claims administrators in accordance with Florida Statutes and Division Rules. Investigates non-payment of orders by a judge and refers findings to the Department. Performs other duties as required.

Requirements

Four (4) years of experience in a relevant field (claims handling, insurance, investigating, audit, accounting, medical billing, or business) is required.
Licensed to operate a motor vehicle.
Ability to travel at least two weeks every month.
Ability to safely operate and rent a motor vehicle.
Knowledge of the principles and techniques of effective communication.
Knowledge of examining and evaluating data.
Knowledge of problem-solving techniques.
Knowledge of conducting fact-finding investigations.
Knowledge of preparing and maintaining records.
Knowledge of writing statistical reports.
Ability to communicate effectively.
Ability to understand and apply appropriate rules, regulations, policies and procedures.
Ability to handle telephone calls and deal with the public in a courteous and effective manner.
Ability to plan, organize and coordinate work assignments.
Ability to work independently.
Ability to establish and maintain effective working relationships with others.
Ability to perform the required position expectations.

Nice To Haves

A post-secondary degree from an accredited college or university may be used as an alternative for years of experience on a year-for-year- basis.
Two (2) or more years of Microsoft Excel.
Two (2) or more years of Microsoft Word.
Two (2) or more years of professional experience in claims handling, medical billing, or insurance.
Knowledge of the Division of Workers’ Compensation data bases i.e., Integrated, EDI Warehouse, OFFIS, and the Centralized Performance System (CPS) Audit Module.
Ability to write audit reports.

Responsibilities

Conducting on-site field audits, desk audits, and re-audits of insurers to ensure proper practices relating to workers’ compensation claims handling procedures.
Monitoring the business practices of insurance companies to ensure their compliance with the workers’ compensation law and administrative rules.
Analysis, examination and/or investigation of patterns and practices of unreasonable delay in claims handling.
Analysis, examination and/or investigation of timeliness and accuracy of payments to injured workers and reports under sections 440.13, 440.16, 440.185, and 440.20, Florida Statutes (F.S.), and Rules 69L-3 and 69L-56, Florida Administrative Code (F.A.C.).
Identifying patterns and practices of harassment, coercion or intimidation of claimants as defined by Chapter 440.525(2), F.S.
Ensuring compliance with medical services billing, filing and reporting under Rule 69L-7.710, F.A.C.
Assisting the Workers’ Compensation Administrator and Government Consultant II in conferring with insurance company personnel and management regarding practices or possible violations of the Workers’ Compensation Law and determining penalties.
Monitoring performance of individual insurers as required by Chapter 440, F.S. and Division Rules, using Division data systems.
Using systems data reviews to determine timely payments of compensation to injured workers and timely filing of forms in compliance with Florida Statutes and Division Rules.
Investigating complaints assigned by the Workers’ Compensation Administrator relating to claims administrators who are non-compliant.
Investigating denied cases to determine questionable claims handling practices by claims administrators in accordance with Florida Statutes and Division Rules.
Investigating non-payment of orders by a judge and referring findings to the Department.
Performing other duties as required.