PART I DEPARTMENT OF PERSONNEL SERVICESSTATE OF HAWAII

. . . .

Class Specificationfor the:

TEMPORARY DISABILITY INSURANCE/HEALTH CARE SPECIALIST SERIES. (TDI/HEALTH CA'RE SPECIALIST).. . . .

Series Definition:

This series includes all classes of positions the duties ofwhich are to supervise and perform professional work involved inthe review, examination and determination of claims benefits andthe examination and determination of whether insurance policies,employers self-developed plans or collective bargaining agree-ments provide benefits equivalent to the minimum requirements ofthe Temporary Disability Insurance (TDI) and Pre-Paid Health Carelaws, rules and regulations.

Temporary Disability and Pre-Paid Health Care are insuranceprograms in which employers are required to provide coverage toall eligible employees for monetary payments to replace wages lostwhen they do not work because of sickness or other disability andto cover medical service benefits. Benefits are provided foreligible workers whose sickness, injuries or disabilities areincurred for reasons other than their employment. Coverage can beprovided through the purchase of' insurance policies, development ofthe enployer's own plan (self-insurance, or collective bargaining agreements or inthe case of health protection, membership in a health care association.

A. Claims Examination~

The actual amounts, duration, and kinds of benefits to beprovided to claiming employees are determined by the insurancecarriers, self-insured employer or health-care contractor.However, in the case of TDI, all rejections of claims arereviewed by positions in this series to determine whether suchrejections were appropriate under provisions of the approvedplan, to which the employer subscribed, or to minimum provisionsof law. In the case of Health Care, rejection of employees'claims due to non-payment of premiums may be appealed by theclaimant for State review and are reviewed by positions in thisseries.

In the case of TDI, two additional types of claims arereviewed and examined for approval by positions in this seriesfor payment from a special compensation fund controlled by theState and established from employer contributions and penaltiescollected. They are for those persons who meet the followingcriteria: (a) employees whose employer went out of businessor ban]crupt and consequently did not provide coverage duringthe employees' periods of illness; and (b) unemployed personst~seunemployment insurance benefits were discontinued because ofinability to accept bona fide job offers because of illness or

TDI/HEALTH CARE SPCLT SERIESPART I

Page 2

disability. Claims examination by positions in this seriesinvolves (a) a determination of whether claimants are eligiblefor benefits under the conditions described above, and (b) theamount and duration of benefits.

'B. Plans Evaluation:

The overall plan chosen by the employer to provide TDIand Health Care Services and benefits and the proportions ofemployee-employer contributions to the premium cost or costof administration are subject to examination and approval.Failure to provide coverage through an approved plan is subjectto penalty and may be cause for cessation of business activity.The examination of plans involves a review of the benefitsand provisions of services to make the following determinations~

(1) Temporary Disability Insurance Plans: Examination ofinsurance policies providing TDI benefits is by anotheragency although it may involve prior consultation with~cialists in this series. Positions in this series examineemployers' self-d4veloped plans and collective bargainingagreements providing TDI benefits. Positions in this seriesdetenaine whether (a) all eligible employees are covered;(b) the amount of wages to be replaced is equivalent orpetter to a minimum percentage amount set forth in law;I(c)the duration of payments and any waiting periodrequired are equivalent to statutory minimums through useof conversion tables; (d) the proportion of premium con-tributions between employee and employer is not higher thana statutory maximum and/or that otherwise, the cost to theemployee does not exceed a certain base percentage of hisor her average weekly wage. The examination may alsoentail determination of whether the employer who requestsself insurance is financially solvent. This determinationis based on a current financial statement, prepared by acertified accounting firm other than the employer, and isperformed only for small enterprises. Eligibility forself-insurance consists primarily of determining if theassets of the firm available meet a minimum amount inrela"tion to the number of employees covered. The minimumamounts are determined from a table prepared by professionalaccountants. Difficult financial solvency questions suchas those involving large enterprises or employers who donot provide current financial statements, are referred toprofessional auditors for examination.

(2) Pre-Paid Health Care Plans: Provisions of the health careinsurance plans subffiittedby employers for review areexamined for conformance with provisions similar to thosedescribed for Temporary Disability Insurance plans under(a), (c~ and (d)aJ::ove. Additionally , health care plansare examined to determine whether the benefits, includingkinds of medicalservices provided, are equivalent to

TDI/HEALTH CARE SPECIALIST SERIESPAR.T I

Page 3

services provided by either of the two prevailing healthcare plans in the State, as required by law. Finaltechnical approval of health care plans is by a HealthCare Advisory Council of the Department and.positions inthis series are required to apnear before the Council toexplain findings and make recommendations as requested asto acceptance, rejection or conditional acceptance pendingmodification of the plan. No examination of financial sol-vency of employers wishing to self-insure health carebenefits is performed by positions in these series. Suchdeterminations are referred for examination by professionalauditors.

Positions in this series are responsible for understanding andapplying provisions of the TDI and/or Pre-Paid Health care laws,rules, and regulations, guidelines, interpretations, and precedents;and methods and procedures for collection and evaluation of dataand performance of claims and plans examination work.

positions concerned primarily with the cierical examination ofclaims or plans are not included in this series. Clerical examina-tion of plans and claims includes work such as, review of employers'submissions to determine if they constitute plans previouslys~hmitted and approved by the program; review of plans and claimsto determine if forms are completely filled out and whether requiredattachments, if any, are present; review and approval of TemporaryDisability Insurance Plans which do not stipulate conditions ofbenefits but merely state that "statutory benefits shall be provided,"and related work which does not require the interpretation, analysisand applica.tion of the applica.ble la~vs, rules, regulations andprecedent cases and professional analysis and determination ofacceptance of claims and plans.

Levels in this series are distinguished by the followingfactors: nature and scope of ,,,,ork,nature of available guidelines,originality required, supervision received and exercised, natureand pur~ose of personal contacts, nature and scope of recommenda-tions, 60mmitments and decisions, and knowledges and abilitiesrequired.

This is the first specification for the new class TEMPOPARYDISABILITY INSURANCE / HEALTH CARE SPECIALIST I

DA'rE APPROVED:..i!--I-;l"tt

TDI/HEALTH CARE SPCLT SERIESPART I

Page 4

TEMPORARY DISABILITY INSUR~NCE/EEALTH CARE SPECIAL!ST I. . '(TDr7HEALTIr CAJ;{'EfSP"CLT:r) -- 3.852

Duties Summa~:y:

Receives formal and on-the-job training and assists in atrainee capacity in activities relating to the State TemporaryDisability Insurance and Health Care programs, and performs otherduties as required.

Dist_i.ngu~shi!lg AC?aract~ris.t.ics:

This is a trainee class 'I,,,hichinvolves formal and on-the-jobtraining in a variety of temporary disability insurance and healthcare activities. .A trainee is expected to handle relatively simplecases involving issues which are resolved through examination ofdocumentation, telephone calls to insurance carriers, or employeror claimants. Such cases involve determining whether claims filedagainst the TDI special compensation fund were filed by eligibleclaimants; and whether claims rejected by insurance carriers werefrom ineligible claimants.

A.n incumbent "'lorksunder the close supervision of a higherlevel TDI/Heal th Care Specialist and receives detailed instructions andclose review \1ith each assignment. The degree of instruction andreview received varies with the newness and complexity of theassignment and the progress made by the trainee.

Exampl_e~of Duties ~

Receives orientation and training in the history, purpose andobjectives of the program and pertinent laws, the role and functionof the assigned unit, the use and purpose of TDI and Health Carespecial funds and how they are administered and the requirementsfor receiving benefits from the funds; receives orientation andtraining in the analysis of temporary disability, sick leave, wagecontinuance and health care maintenance plans and claims filedagainst the special disability fund for benefits; reviews claimsand determines validity of same; reviews temporary disability andhealth care plans for employers which provide basic, statutorybenefits and recon~ends approval or identifies problems andrecommends actions required for resolution; analyzes insurers' denialnotices for health care and temporary disability, determines whetherthe denial is appropriate and recommends action required forresolution.

Knowledges and Abilities Required:

~nowledge of.: Social sciences.

Ability to: Learn and apply principles, practices and proce~dures-for the examination of claims and plans; learn, understandand apply pertinent provisions of the Hawaii Temporary DisabilityInsurance or Pre-Paid Health Care laws, rules, and regulations;obtain, analyze and evaluate facts; deal effectively with others.

PART I DEPARTMENT OF PERSONNEL SERVICESSTATE OF HAWAII

3.853

.................................

Class Specificationfor the Class:

TEMPORARY DISABILITY INSURANCE/HEALTH CARE SPECIALIST II(TDI/HEALTH CARE SPCLT II)

Duties Summary:

Performs the full range of Temporary Disability Insurance(TDI) claims examination and denial of benefits review; assistsand participates in the review of TDI and Health Care plans;receives advanced training; and performs other duties as required.

Distinguishing Characteristics:

This class reflects responsibility for performing the fullrange of TDI claims examination and review of denial of benefits,for receiving advanced training and for assisting higher levelspecialists in TDI and Health Care Plans review. The scope ofwork includes independently receiving and reviewing the full rangeof claims for TDI benefits against the special compensation fundand reviewing denials of TDI or Health Care benefits. TDIresponsibilities include developing information, clarifying andverifying facts; determining eligibility of the applicant andduration and kind of benefits due; determining the appropriatenessof denial based on clearly defined procedents, rules and regula-tions and other guidelines; and recommending approval or disapprovalof claims or denials of benefits. Positions also review the lesscomplex TDI plans submitted by employers where the review consistsof a comparison of the plan against statutory benefits, includingdetermining whether basic elements such as eligibility and benefitprovisions are appropriate; the appropriateness of the employee-employer premium sharing aspects and assisting in calculatingoverall equivalency of other than statutory plans through the useof a factor table. A position in this class also receives trainingand assists higher level specialists in reviewing nonstandard TDIplans and new prepaid Health Care plans against standardsestablished in the law by identifying and describing benefits andpreparing preliminary analyses.

The work is controlled by established procedures and prece-dents. Incumbents are responsible for the accuracy of information,computations and comparisons and apply methods and procedures forclaims examination without substantial guidance. An incumbent isresponsible for recognizing and requesting more guidance on com-plex cases or those without applicable precedents. Supervisionis general on more routine assignments and closer in more complexareas such as plans review. Assignments of a complex nature maybe given for training purposes.

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Examples of Duties:

TDI: Receives and reviews temporary disability claims toidentify those that are chargeable against the special fund; ensuresthat all medical, wage and employment reports, pertinent unemploy-ment insurance notices and other related documents are on file;reviews the information to determine whether the claim is valid orinvalid; prepares denial notices to be sent to the claimant forinvalid claims; approves valid claims and processes monetarydeterminations to be distributed to the claimant and others;receives and reviews continued claims and approves and preparesnecessary documents for processing continued benefit payments;determines when additional updated medical records are required,secures them and completes review for claims; receives and reviewsinsurers' written denial of benefits for TDI; determines whethergrounds for denial are appropriate relative to requirements of thelaw and/or provisions of the insurers' plan; contacts the insurerto notify and explain reasons as to why their denials are deficientand remands cases for reconsideration; explains to claimants theirappeal rights and the department's appeal process and may assistthem in filing an appeal; receives denials of health care benefitsdue to nonpayment of premium; verifies facts; may refer case forenforcement action; receives training in, and as competence isacquired, independently receives and reviews employers' statutoryplans for the provision of temporary disability insurance coveragefor employees; verifies whether the plan complies with statutoryrequirements in terms of duration, employee-employer share of thepremium, qualification requirements and related features; notifiesthe employer if the plan is invalid, pointing out necessaryrevisions to correct inadequacies; identifies factors to be usedin determining equivalency for nonstatutory plans; using thefactor table, computes equivalence factor and makes recommendationas to the acceptance or rejection of the plan; may receive andprocess employers' registration.

Health Care: Receives advanced training and orientation andassists higher level specialists in reviewing new health careplans against the most prevalent plans by identifying and record-ing the provisions of such plans; reviews and approves employers'exemptions of certain employees from health care plan coveragefor straightforward reasons such as, coverage by a federallyestablished plan or as a dependent under spouse's qualified healthcare plan or as a member of a religious group whose beliefs donot permit such coverages.

General: Explains provisions of the TDI and Health Care lawsto employers, employees, insurance carriers and others; mayprepare necessary computer forms to input data regarding healthcare and TDI plans; prepares reports.

Knowledges and Abilities Required:

Knowledge of: Principles and techniques of claims examina-tion; interviewing methods and techniques; report writing.

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Ability to: Understand and apply State TDI and Health Carelaw, rules and regulations relating to benefit provisions, coverageand exempted services, methods of computation of average weeklywages and maximums, definition of primary and secondary employer,premium payment requirements, and development of plans; learn andapply principles of plans examination; obtain information fromothers orally and in writing; deal effectively with claimants,employers and insurance carriers; prepare written reports; analyzeand evaluate facts, rules and regulations, claims and precedentcases.

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This is the first specification for the new class TEMPORARYDISABILITY INSURANCE/HEALTH CARE SPECIALIST II.

DATE APPROVED: Izhf/7'

PART I DEPARTMENT OF PERSONNEL SERVICESSTATE OF HAWAII

3.854

..................................

Class Specificationfor the Class:

TEMPORARY DISABILITY INSURANCE/HEALTH CARE SPECIALIST III(TDI/HEALTH CARE SPCLT III)

Duties Summary:

Reviews and recommends the approval or disapproval of plansand TDI provisions of collective bargaining agreements submittedby insurance carriers and employers to meet requirements of theTDI and Health Care laws, rules and regulations of the State; andperforms other duties as required.

Distinguishing Characteristics:

This class reflects responsibility for independently reviewingthe full range'of TDI plans submitted by self-insured employersand of TDI provisions of collective bargaining agreements for con-formance with statutory requirements and for performing moderatelycomplex health care plans review. TDI plans review work includessignificant difficulties such as an employer having several classesof employees reflecting different methods of coverage and/orexcluded services and regularly involves the determination ofoverall equivalency where benefits of the plans are at variancewith basic statutory requirements. The scope of work also includesthe determination of financial solvency for small businesses todetermine their eligibility for self-insurance through the use offactor tables and advising and assisting employers as to how non-complying plans can be brought into conformance with statutoryrequirements. Work in the examination of health care plansinvolves the identification of services and benefits, qualifyingrequirements and other factual information and comparing the planwith models established by law and/or precedent plans approved bythe Health Care Advisory Council. A position in this class reviewsthe full range of health care plans but assignments are typicallylimited to moderately complex plans where there are significantvariables in features from those models established by law butwhere such variables are limited in number.

Positions also assist higher level specialists and participatein reviewing plans submitted by individual employees seeking awaiver from coverage by the employer's group health care plan.Certain positions in this class may also perform the most difficultand complex claims examination and denials of benefit cases wherethe claims or denials exhibit unusual or unique problems orfeatures. Health care plans review includes responsibility forattending Health Care Council meetings to answer questions andexplain aspects of the plans as requested; taking notes andfollowing up independently with the insurer or health care con-tractor for corrective actions required for the plan to conform

TOI/HEALTH CARE SPCLT IIIPART I

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to requirements as specified by the Council. Some positions mayalso perform, in addition, a significant amount of work of thenext lower level.

Positions work within established policies, procedures, methodsand standards. Guidelines are the law, rules and regulations,precedent cases, and internal guidelines. In addition, in healthcare plans examination, guidelines consist of precedent decisionsrendered by the Health Care Advisory Council in the form of casesreflecting "substantial equivalency of plans," since the lawpermits substitution of benefits equal to or medically reasonablysubstitutable for specified benefits. A position in this classwill be required to apply discretion and judgment in the determi-nation of whether given combinations of plans' benefits andfeatures meet models established by law or substantial equivalencyprecedents and guidelines.

Positions are under the general supervision of a higher levelspecialist and assignments are carried out independently withoutconsultation with the supervisor except in cases of unusualdifficulty or complexity. Work in the more complex areas of healthcare plans review are subject to review for soundness of recommen-dations and overall conformance with Council requirements, programstandards, policies and guidelines.

Examples of Duties:

TOI: Receives and reviews the full range of TOI plans sub-mitted by self-insuring employers or of the TOI provisions ofcollective bargaining agreements for conformance with statutoryrequirements and equivalence; gathers pertinent information anddetermines that all eligible employees are covered; identifiesfeatures of the various methods of coverage used for each group ofemployees; determines whether provisions of the planes) and/orcollective bargaining agreements are in conformance with minimumrequirements of the statute or are equivalent; computes equivalenceusing a conversion table; rejects unsuitable plans and advisesthe employer or union as to steps required to render the planacceptable; reviews financial statements for small enterprises todetermine whether the employer is financially solvent such that hecan self-insure; refers for professional auditing review thoseemployers seeking self-insurance when the enterprise is largeand/or financial statements are not available; may review the mostdifficult claims referred by lower level specialists-as assigned;identifies problems and makes recommendations where the claiminvolves a precedent-setting decision or interpretation and appli-cation of the law.

Health Care: Receives and reviews health care insuranceplans; identifies services, benefits, exclusions and related factsregarding the plans; prepares a worksheet and makes comparisonwith models established by law and/or precedent plans approved bythe Council; makes recommendations as to deficiencies, favorablefeatures and related matters and recommends approval, disapproval

TDI/HEALTH CARE SPCLT IIIPART I

,...3- 3.854

or conditional approval; attends Health Care Council meetings toprovide information regarding the plans and to explain aspects ofthe plans as requested; takes notes and follows up with the appli-cable insurance carrier or health care contractor as to correctiveactions required for conformance with Council requirements; partici-pates in reviewing health care plans submitted by individualemployees by extracting pertinent information as to the nature,duration and related aspects of the varied components of the plan.

General: May review appealed TDI cases before referral to theTDI appeal referees, contacting the claimant where the claim isclearly invalid to attempt to obtain withdrawal of the appeal;refers TDI and Health Care cases for investigation and enforcement;may analyze cases ,of subrogation and make recommendations; answersinquiries; prepares correspondence and reports and may assist inthe registration of employers.

Knowledges and Abilities Required:

Knowledge of: State TDI laws, rules, and regulations relatingto benefit provisions, coverage and exempted services, premiumsharing, computation of average weekly wage and maximums, anddefinition of primary/secondary employer; State Pre-Paid HealthCare laws, rules, and regulations relating to benefit provisions,coverage, exempted services, premium, primary/secondary employer;guidelines established by the Council (as available) on makingdeterminations of substantial equivalency.

I

Ability to: Understand, interpret and apply TDI and HealthCare laws, rules, and regulations; read and derive patterns ofapproval of precedent cases established by the Council to be usedfor determining substantial equivalency; elicit information fromothers orally and in writing; deal effectively with employers,insurance carriers or health care contractors; prepare writtenreports; analyze and evaluate facts, plans, rules, regulations andprecedent cases.

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This is the first specification for the new class TEMPORARYDISABILITY INSURANCE/HEALTH CARE SPECIALIST III.

DATE APPROVED: IZ/9 /79I r OTELHOersonnel Services

PART I DEPARTMENT OF PERSONNEL SERVICESSTATE OF HAWAII

3.855

.................................

Class Specificationfor the Class:

TEMPORARY DTSAHILITY INSURANCE/HEALTH CARE SPECIALIST IV(TDI/HEALTH CARE SPCLT IV)

Duties Summary:

Performs the most difficult and complex health care plansreview and acceptance activities as a regular assignment; andperforms other duties as required.

Distinguishing Characteristics:

This class reflects primary and predominant responsibility forperforming the most difficult and complex health care plans reviewand acceptance assignments. Assignments at this level reflectsignificant difficulties including factors such as, multiplecoverage; multiple benefits and features at variance with standardmodels as specified by law or precedents; the provision of consul-tative and advisory services to insurance carriers or health carecontractors to assist them in developing acceptable health careplans meeting the requirements of the Health Care Advisory Counciland the law; active participation in Council discussions byrecommending approval, disapproval or conditional approval of plansincluding pointing out features for special consideration by theCouncil; and the independent review of individual employees' plansfor those who apply for exemption from joining their employer'sgroup benefit plans where a broad range of variables in the benefitsare offered and a thorough analysis of all features is requiredincluding limitations, deductions, premium contribution, dependents'coverage, relation of premium to benefit, identification of subtlegaps in provisions and the like. A position in this class mayalso perform the analysis and evaluation of more difficultTemporary Disability Insurance plans including the resolution ofunusual or unprecedented problems.

Guidelines are the same as identified for the next lowerlevel; in addition, positions in this class require thoroughknowledge of Council requirements, precedents and divisionalstandards when advising insurers or health care contractors in thedevelopment of new plans which would be acceptable to the Council.

A position in this class is under the general supervision ofa higher level TDI/Health Care Specialist. Incumbents areexpected to carry out assignments independently and to notify thesupervisor only of unusual activities or to consult with thesupervisor when need arises.

Recommendations relative to the acceptance or rejectionofHealth Care insuranceplans or health care contractsare given a

TDI/HEALTH CARE SPCLT IVPART I

3.855

final full evaluation by the Health Care Advisory Council of thedepartment.

Person-to-person contacts are significant and are with theemployers, insurance carriers and others to notify them of non-conforming aspects of their submitted plans and to advise andassist them in adjusting plans or in developing new plans to con-form with Council and statutory requirements.

Examples of Duties:

Reviews health care plans submitted by insurance carriers orcontractors; assesses and analyzes all conditions of the plan(s)including premiums, co-insurance clauses, deductibles, benefitsand services, exclusions, gaps in provisions, overlaps, servicesover the minimum statutory requirement such as vision and dentalfeatures and other related factual elements of the plan; comparesplan with requirements of the law and/or precedent plans of theCouncil where applicable; determines whether, overall, the plan'sprovisions and features are at least as favorable as thoseprovided by law; recommends approval, disapproval or conditionalapproval pending corrective action; attends Health Care Councilmeetings to explain and provide information regarding the plans;points out favorable, unfavorable or non-conforming aspects ofthe plan and recommends, if requested, corrective action required;takes notes and independently follows up on corrective actionrequired; meets and discusses with insurance carriers or healthcare contractors, requirements of the Hawaii law and of theCouncil; advises them on construction of their proposed plan(s)so as to meet statutory and Council requirements; reviews healthcare plans submitted by individual employees seeking to waivetheir coverage under their employer's group benefit plans;evaluates the benefits, services and features of the plan todetermine whether they are at least as favorable as required bylaw; counsels and advises them as to whether gaps exist and asto the kinds of services and benefits which should be incorporatedinto the plan to make it comparable to statutory requirements;may review very complex and unique TDI plans referred from lowerlevels; identifies problems and makes recommendations for resolu-tion where the interpretation and extension of precedents orguidelines currently available are involved; may refer cases forinvestigation and enforcement action; may analyze subrogationrequests; answers inquiries regarding the TDI and Pre-Paid HealthCare laws, rules and regulations and prepares correspondence andreports.

Knowledges and Abilities Required:

Knowledge of: State TDI laws, rules and regulations relat-ing to benefit provisions, coverage and exempted services, premiumsharing, computation of average weekly wage and maximums, anddefinition of secondary/primary employer; State Pre-Paid HealthCare laws, rules and regulations relating to benefit provisions,coverage, exempted services, premium, primary/secondary employer;

TDI/HEALTH CARE SPCLT IVPART I

3.855

guidelines established by the Council (as available) on makingdeterminations of substantial equivalency.

Ability to: Understand, interpret and apply TDI and HealthCare laws, rules and regulations; read and derive patterns ofapproval of precedent cases established by the Council to be usedfor determining substantial equivalency; elicit information fromothers orally and in writing; deal effectively with employers,insurance carriers and health care contractors; prepare writtenreports; analyze and evaluate factors, plans, rules, regulationsand precedent cases.

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This is an amendment to the specification for the classTE~1PORARYDISABILITY INSURANCE/HEALTH CARE SPECIALIST IVwhich was approved on May 31, 1977.

DATE APPROVED:~ BOTELHOersonnel Services

PART I DEPARTMENT OF PERSONNEL SERVICESSTATE OF HAWAII

3.856

.................................

Class Specificationfor the Class:

TEMPORARY DISABILITY INSURANCE/HEALTH CARE SPECIALIST V(TDI/HEALTH CARE SPECIALIST V)

Duties Summary:

Supervises the operations of a program for claims examinationand the statewide review and approval of plans for the TemporaryDisability Insurance and Pre-paid Health Care programs of the State;and performs other duties as required.

Distinguishing Characteristics:

This class involves responsibility for supervising the opera-tions of a program for claims examination and the statewide reviewand approval of plans for the provision of Temporary DisabilityInsurance (TDI) and Health Care Insurance benefits. Activitiesinclude examination of claims for TDI benefits filed by employeeswhose employers could not provide benefits because they went outof business or were bankrupt, or by unemployed persons whoseunemployment insurance benefit payments were discontinued becausethey failed to accept a bona fide job affer due to temporary ill-ness or disability; examination of claims rejected for healthcare and temporary disability benefits to determine if they wereappropriately rejected and in accordance with statutory require-ments or requirements of the employers' plans; examination ofpre-paid health care insurance policies or health care contractsand TDI and Health Care employers' self-developed plans or collectivebargaining agreements to determine if provision of the policies,contracts, plans or agreements meet statutory requirements.

A position in this class serves as a branch chief and directsprofessional and clerical supportive staff under broad divisionalguidelines and general technical and program direction fromProgram Officers responsible for the TDI and the Pre-paid HealthCare programs. A position in this class is responsible for thedevelopment of operational policies and guidelines and the determi-nation of operational priorities within program guidelines estab-lished by the Program Officers. A position in this class isresponsible for resolving operational problems, coordinating allbranch activities, and ensuring technical adequacy of the work.Supervisory review at this level is limited to conformance withoverall program, divisional and general administrative guidelinesand technical decisions are not normally questioned. However,matte~s relating to the interpretation and application of the law,rules and regulations which are not covered by existing policiesor precedent cases are discussed with the Program Officer responsi-ble for the functional area applicable and/or division administrator;

TDI/HEALTH CARE SPECIALIST V -2-

although a position in this class is expected to be able to makea recommendation as the handling and disposition of the immediatecase involved and as to policy and/or procedures to handle futuresimilar or related cases.

Examples of Duties:

Supervises the operations of a program for claims examinationand for the statewide review and approval of plans for the pro-vision of temporary disability and health care benefits to eligibleemployees of Hawaii; supervises the examination of claims fromemployees whose employers became bankrupt or went out of businessand from unemployed persons whose unemployment insurance benefitswere terminated because of failure to accept a bona fide joboffer because of temporary illness or disability; directs andsupervises the review of TDI claims rejected by insurance carriersor self-insured employers or others to determine if rejections werein accordance with statutory requirements or in conformance withprovisions of the insurance policy, employer's plan or any appli-cable collective bargaining agreement; directs and supervises thereview of claims for health care which were rejected and appealedbecause of failure of the claimants to pay their premium, todetermine the facts and to attempt to resolve the claim withoutresort to formal hearing; supervises the examination of health careinsurance policies or contracts and all employer-developed plansand collective bargaining agreements providing TDI and Health Carebenefits to determine if they provide minimum statutory benefitsto covered employees and that employee contributions toward theplan do not exceed maximum statutory requirements; supervises thereview of health care plans of individual employees who waivecoverage under their employees' group medical plans to ensurebenefits and features are at least as favorable as required bylaw and/or precedent decisions by the council; establishes branchoperational objectives and determines and recommends changes forimprovements such as procedural changes, staff development train-ing, improved methods, techniques and procedures, increasedresources for staff, equipment and other operating expenditures;conducts staff meetings to discuss operational problems and toensure uniform understanding, interpretation and application oflaws, standards, policies, rules and regulations; recommendsappropriate action on personnel matters such as appointments,promotions, transfers, leaves of absences and disciplinary problems;determines and recommends changes of work schedules; refers casesto other branches for investigation; directs the scheduling oftemporary disability insurance appeals hearings; may examine claimsand review and approve plans.

Knowledges and Abilities Required:

In addition to the knowledges and abilities required at thenext lower level, this class requires knowledge of the operations,programs, policies and legal requirements pertinent to the claims

TDI/HEALTH CARE SPECIALIST V -3-

examination and plan review program; principles and practices ofsupervision, ability to assign and review the work of others;ability to deal effectively with subordinates, prepare comprehen-sive written reports and make sound judgments on difficult andcontroversial cases.

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This is the first specification for the new class TEMPORARYDISABILITY INSURANCE/HEALTH CARE SPECIALIST V.

DATE APPROVED:,,/:z'/77

/ ...,..,TELHO

~ersonnel Services