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A32 Insurance Benefits Specialist

Basic Purpose

Positions in this job family are assigned responsibilities involving the performance of professional and technical work relating to the administration of health, dental, pharmacy, disability and life insurance programs for state, educational and local government employees and retirees.  This includes development, preparation and analysis of utilization and cost reports and preparation of proposals for benefit or procedural changes.

Typical Functions

The functions within this job family will vary by level, but may include the following:

  • Develops and/or prepares reports concerning delivery of medical services or equipment.
  • Prepares cases for review by medical, dental or other professional consultants or staff.
  • Develops, prepares and/or analyzes reports relating to benefits, claims or health promotions.
  • Assists in the evaluation and development of proposals regarding benefit structure.
  • Assists in the creation and maintenance of case management files.
  • Develops, prepares, and/or analyzes reports relating to benefits, claims, or health promotions.
  • Develops and implements policies and procedures relating to unit operation.
  • Analyzes benefit delivery and utilization issues and communicates to division director and administration.

Level Descriptors

The Insurance Benefits Specialist job family has four levels which are distinguished by the complexity of assignments, the level of expertise required to perform the duties assigned and the responsibility for providing leadership to others.

Level I: Code: A32A Salary Band: G

This is the basic level of the job family where employees are primarily responsible for performing routine entry level work in a training status to build their skills in case preparation and review, benefit structure analysis, claims auditing and analysis, and report preparation and analysis.

Knowledge, Skills and Abilities required at this level include knowledge of state and federal laws pertaining to health, dental, pharmacy, life and disability insurance programs; of basic medical claims processing requirements and procedures; of medical and dental terminology; and of basic insurance benefits and industry guidelines. Ability to review and analyze medical, dental, pharmacy, disability or life claims; to evaluate medical reports, narratives and treatment plans; to gather, organize and report information; to communicate effectively, both orally and in writing; to interpret and explain insurance laws; and  to establish and maintain effective working relationships with others.

Education and Experience requirements at this level consist of a bachelor’s degree and one year of experience in the health insurance industry in areas such as benefits analysis, claims review or analysis, or medical/dental review or report preparation; or an equivalent combination of education and experience, substituting one year of qualifying experience for each year of the required degree.

Level II: Code: A32B Salary Band: H

This is the career level of the job family where employees are assigned duties and responsibilities at the full performance level and perform a wide range of tasks involving preparation and analysis of reports to determine cost benefits ratios, benefit utilization patterns and cost/utilization projections; development and analysis of benefit structures; and maintenance of case management files.  This includes maintenance of standard reports.  At this level, limited training and supervision may be provided to technical or entry level employees in this job family.

Knowledge, Skills and Abilities required at this level include those identified in Level I plus ability to develop report parameters to evaluate utilization of medical services and equipment;  to perform cost benefit analysis; and  to prepare projections of program utilization and costs.

Education and Experience requirements at this level consist of those identified in Level I plus one additional year of qualifying experience.

Level III: Code: A32C Salary Band: I

This is the specialist level of the job family where employees are routinely assigned responsibilities for advanced level analysis involving the development and analysis of complex reports and program development.  The work is generally performed with a high degree of technical and administrative freedom to plan, develop and organize all phases of the work necessary for completion within the program guidelines.

Knowledge, Skills and Abilities required at this level include those identified in Level II plus the ability to perform highly independent work, make independent decisions, and analyze and resolve benefits problems and issues.

Education and Experience requirements at this level consist of those identified in Level I plus two additional years of qualifying experience.

Level IV: Code: A32D Salary Band: J

This is the leadership level where employees are assigned responsibility for directing and supervising the work activities of the assigned unit on a regular and consistent basis.  This includes responsibility for planning, organizing, reviewing and evaluating the work of an assigned staff as well as performing related administrative functions.

Knowledge, Skills and Abilities required at this level include those identified in Level III plus knowledge of supervisory practices and principles.  Ability to supervise and direct the work of others.

Education and Experience requirements at this level consist of those identified in Level III.

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