The work involves responsibility for participating in the administration of a local health insurance program by assisting enrollees in the preparation and submission of claims by reviewing forms and transactions for conformity to standard procedures and by reviewing computer listings and manual records pertaining to enrollment and/or deduction to check accuracy and gathering information to explain or solve errors associated with the insurance program. An employee in this class works under the direct supervision of the Employee Insurance Representative in a self insured environment. An employee in this class exercises no supervision.





Enrolls employees in health insurance program by advising on how to complete enrollment forms, typing out information and advising them on available medical and/or dental coverage.

Determines the amount of premium shares to be collected for employees receiving survivor's benefits and on authorized leave without pay by subtracting additional coverage from the amount of premium increase multiplied by the number of months.

Collects employee premium shares by insuring that the employee and the employer made arrangements to pay premiums while on leave without pay, bills them for the month or quarter due and bills all available survivors where necessary.

Computes monthly bills by tabulating and recording premium rates to be charged employee each pay period, tabulating and recording amount of Medicare payments to be refunded, and computing the amount of reimbursement due to employee from the insurance claim.

Verifies eligibility for enrollment in the health insurance program by checking the day the employee began work and ascertaining the employee works a minimum of twenty hours a week and processes applications of late enrollees into the program upon determining their eligibility.

Processes claims by inserting information on original claim forms and insuring all necessary information is present before authorization.

Audits claims by reviewing statements to insure all dates are in calendar year and that there is a record of diagnosis; itemizing all medical bills computing the amount of claim payment and issuing checks to employees for major medical claims paid by the insurance carrier.

Computes federal and state reimbursements for department claim premiums by keeping record of number of people in the department, filling out original claim forms and computing the amount of reimbursement.

Contacts doctors, hospital personnel, insurance personnel and government agencies regarding prognosis and diagnosis of employees ailment to insure that the employees are covered for all aspects of their claims.

Notifies employees who recently turned 65 years of age of the coverage entitled to them under medicare, and keeps records of active employees for their annual medicare reimbursement.

Compiles monthly report including the number of employees covered during the last and present periods, and all deletions and additions to the enrollment of the employment health insurance program the former involving the notification of employees not covered by the local program regarding privileges of converting to alternate health insurance coverage.




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Good knowledge of rules, regulations and procedures regarding eligibility for health changes in coverage, and waiting periods for late enrollees.

Good knowledge of health insurance rates, types of coverage, deductions, credits and billing procedures.

Good knowledge of rules, regulations and procedures regarding submission of major medical claims.

Working knowledge of medical terminology as it relates to prognosis and diagnosis as recorded in major medical claims.

Ability to communicate effectively in the office or over the telephone in explaining the provisions of the insurance program to employees and enrollees.

Ability to identify significant factors in claims and eligibility problems and the ability to reach logical conclusions based upon an analysis of these factors.

Physical condition commensurate with the demands of the position.





Open Competitive


One (1) year of work experience, or its part time equivalent, in verifying and processing insurance claims, or in reviewing and processing other benefit program eligibility criteria.



01/2008 Revised