CLAIMS REVIEWER DEFINITION: Under the close supervision of a Principal Claims Reviewer or other supervisory official, examines and makes eligibility determinations on claims related to financial and/or health care services in health or human services programs and/or investigates the potential of third-party liability for recovery of funds; does other related duties as required.
NOTE: The examples of work for this title are for illustrative purposes only. A particular position using this title may not perform all duties listed in this job specification. Conversely, all duties performed on the job may not be listed.
EXAMPLES OF WORK:
Reviews and processes applications and claims to determine eligibility for financial and/or health care benefits and services.
Calculates earned and unearned income for individuals to determine eligibility.
Contacts various government agencies, providers, and recipients to gather information for eligibility determinations.
Assists in initiating the investigation and resolution of eligibility data discrepancies identified through various reports.
Reviews and authorizes the processing of eligible health care provider claims; submits approved claims to a health care fiscal agent for reimbursement.
Reviews client eligibility and profile reports; determines viability for recovery of financial and health care service funds.
Contacts providers, clients, and insurance companies to obtain information for the recovery of previously expended funds.
Investigates the potential of third-party liability for recovery of funds.
Receives and initiates transmittal of recovered funds; prepares the filing and discharge of liens.
May review system exception reports and initiates corrective action.
Responds to routine inquiries and assists applicants with obtaining, transferring, or returning benefits; interprets and explains State and federal rules and regulations regarding health or human services programs, or laws related to other State financial aid programs. (Examples of health or human services programs may include Medicaid, Lifeline Utility Assistance, etc.).
Refers cases of suspected fraud and abuse; provides information on cases to be litigated.
Compiles data and prepares reports of activities.
Compiles documentation for hearings.
Prepares correspondence.
Initiates updates of various files and records of case activity.
Establishes and maintains records and files.
Will be required to learn how to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.
REQUIREMENTS:
NOTE: Applicants must meet one of the following or a combination of both experience and education. Thirty (30) semester hour credits are equal to one (1) year of relevant experience.
Five (5) years of professional experience in the evaluation and/or verification and eligibility determination of applications for financial or medical assistance, benefits or other health or human services programs, or in credit investigations for recovery of funds.
OR
Possession of a bachelor's degree from an accredited college or university; and one (1) year of the above-mentioned professional experience.
NOTE: "Professional experience" refers to work that is analytical, evaluative, and interpretive; requires a range of basic knowledge of the profession's concepts and practices; and is performed with the authority to act and make accurate and informed decisions.
LICENSE:
Appointees will be required to possess a driver's license valid in New Jersey only if the operation of a vehicle, rather than employee mobility, is necessary to perform the essential duties of the position.
KNOWLEDGE AND ABILITIES:
Knowledge of applicable financial and/or health care services and programs offered in New Jersey.
Knowledge of modern business office routines and their practical application.
Knowledge of the techniques used to obtain information, review, and evaluate eligibility claims.
Ability to read and interpret laws, rules, and regulations, and apply them to specific situations.
Ability to compile information needed for eligibility determinations.
Ability to establish and maintain cooperative working relationships with clients, providers, and others.
Ability to review and determine the validity of eligibility claims.
Ability to identify suspected cases of fraud and abuse of claims.
Ability to prepare correspondence and reports containing findings, conclusions, and recommendations.
Ability to establish and maintain records and files.
Ability to learn how to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.
Ability to read, write, speak, understand, and communicate in English sufficiently to perform duties of this position. American Sign Language or Braille may also be considered as acceptable forms of communication.
Persons with mental or physical disabilities are eligible if they can perform the essential functions of the job with or without reasonable accommodation. If the accommodation cannot be made because it would cause the employer undue hardship, such persons may not be eligible.
