CLAIMS EXAMINER UNEMPLOYMENT & DISABILITY INSURANCE BILINGUAL IN SPANISH AND ENGLISH
DEFINITION:
Under the close supervision of a supervisory official in the New Jersey Department of Labor and Workforce Development, assists in making decisions on irregular, complex, and/or disputed unemployment or disability benefit claims; makes non-monetary determinations of eligibility under New Jersey Unemployment Compensation Law; or performs technical and detailed work involved in the approval and termination of privately administered disability insurance plans and reviews irregular and disputed claims from private plans; or performs technical, evaluative, and investigative work to determine eligibility of claimants under New Jersey Temporary Disability Insurance (TDI) Law; does other related duties as required.
NOTE: Appointments may be made to positions requiring bilingual skills.
56092C - Bilingual in Spanish and English SPECIAL SKILL Applicants must be able to read, write, speak, understand, or communicate in Spanish and English sufficiently to perform the duties of this position.
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:
Interviews claimants by phone and in person to obtain facts to make informed decisions; advises claimants of their rights and responsibilities under Temporary Disability or Unemployment Insurance Law and refers them to federal Social Security, New Jersey Workers' Compensation, and other insurance programs where applicable.
Collects information from employers for making decisions on eligibility of benefits according to law, policy, and procedure.
Resolves unemployment and disability issues; makes non-monetary determinations, advises claimants of appeal rights, and notifies interested parties.
Answers questions from claimants, employers, and the public.
Processes overpayments, adjustments, and refunds when required.
Prepares and submits statistical production reports.
Requests wage and separation information from employers and computes monetary determinations.
Interviews claimants regarding interstate claims, makes recommendations of eligibility, forwards necessary correspondence to the liable state, and informs the liable state of current labor market conditions.
Conducts initial and subsequent periodic interviews to determine continuing eligibility (Benefit Claim form BC-26.3D).
Processes initial claims and continued claims at the counter when required.
Testifies as a witness at the Appeal Tribunal hearings to defend and explain non-monetary determinations.
Processes mail claims (BS-260's) and other correspondence when required.
May take appeals according to law, policy, and procedure, and advises claimants of reporting requirements.
May receive refund payments and prepare receipts.
May provide instruction and guidance to Unemployment Insurance Clerks.
Maintains daily activity tallies for (BC-120) transmittal and may prepare statistical reports.
Advises Bureau of Benefit Payment Control of possible illegal payments or overpayment of benefits.
Reviews irregular mail claims to discern if additional information is required to make a non-monetary determination; provides appropriate forms as needed.
May advise claimants of human resources and social agencies that can assist during unemployment.
Reviews labor market data and utilizes precedent manual for making proper determinations.
Evaluates and interprets medical certification to determine eligibility.
Initiates request for refund of unemployment benefits paid during a period of disability.
Examines and resolves discrepancies in applications and supplementary material submitted by employers and physicians.
Requests required information from no-fault insurance carriers upon receipt of claims for reimbursement of disability benefits paid by automobile insurance carriers.
Processes requests from claimants to extend disability payments.
Examines claims for authenticity, authorizes payment of disability benefits for initial and continued claims, and recommends fraud investigations as needed.
Screens all applications to determine which bureau will be assigned to each claim and forwards to the proper section.
Reviews claims to determine employee coverage.
Reviews reports for information on plan modifications, status of employer, and whether employer is covered under TDI Law. Establishes benefit rights and initiates authorization of benefit payments to eligible claimants.
Gathers medical certification from treating physicians and other resources; arranges and reviews impartial physical examinations to determine if claimants are genuinely disabled and eligible for continuation of benefits.
Processes contested Workers' Compensation cases when authorized.
Provides explanation of monetary and non-monetary determinations of eligibility in response to claimant, attorney, and employer appeals.
Reviews original state benefit eligibility or ineligibility decisions based on informal claimant and employer appeals, and Appeal Tribunal or Board of Review decisions.
Provides information on claim status to Social Security Administration Disability Determinations and welfare agencies.
Processes claims for reimbursement of benefits to no-fault insurance carriers.
Contacts unemployment insurance offices by phone to gather information that impacts eligibility or ineligibility of benefits.
Analyzes and resolves conflicts to finalize irregular, disputed, and long-delayed claims.
Reviews requests for private plans to be terminated, and determines if they are valid under the law. Reinstates private plans based on timeliness of termination requests received.
Assists concerned parties with private plan modifications to ensure compliance with TDI Law changes.
Analyzes reports to determine circumstances of probable employer successions and the effect on existing private plans.
Requests Review Unit to contact private plan insurers, claimants, unions, and hospitals to obtain additional data to help resolve problems with administration of private plans.
Scrutinizes new insurance policies, riders and amendments, certificates of insurance, employer notices, and union bargaining agreements to determine acceptability under the TDI Law and/or in conjunction with the New Jersey Department of Banking and Insurance.
Communicates with Workers' Compensation Division, private plan insurers, claimants, and attorneys to resolve issues related to subrogation of the law.
Reviews proof of change in order to determine the appropriate action for updates to name, address, registration number, effective and withdrawal dates, and other conditions of private plan coverage according to existing procedures.
Arranges to secure reimbursement of monies by private plan insurers to the State plan 4(f) and other insurance companies for claims erroneously paid; recoups monies for insurers from the state plan.
Conducts informal hearings to advise insurers on points of the law and agency policy; arranges formal hearings for claimants to meet with private plan hearing officers if attempts to get claims amicably settled have failed.
Reviews existing unemployment claims to establish claimant was in the labor market and eligible for unemployment benefits, but unable to work.
Establishes unemployment claims and authorizes payment of unemployment benefits for the period prior to period of disability.
Collects additional information required from local unemployment offices to process claims.
Calculates unemployment disability balances according to the established formula.
Informs Bureau of Benefit Payment Control about possible wage/benefit conflicts.
Files new and transitional unemployment claims on claimant's behalf.
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 investigation, review, analysis, evaluation, and eligibility determination of claims for unemployment and/or insurance compensation in a public or private organization.
OR
Possession of a bachelor's degree from an accredited college or university; and one (1) year of the above-mentioned professional experience.
NOTE: For incumbents in the title of Senior Unemployment Insurance Clerk, substitution for education and experience is as follows: Employees serving in the title of Senior Unemployment Insurance Clerk (or the bilingual variants) for a minimum of two (2) years and meeting the permanent status requirement listed on the announcement will be eligible for the promotional examination for Claims Examiner Unemployment and Disability Insurance (and the bilingual variants).
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 interviewing techniques.
Knowledge of insurance claims processes.
Knowledge of changes in the law affecting determination and administration of claims.
Knowledge of appeal procedures.
Knowledge of Workers' Compensation Law.
Knowledge of social agencies that can assist claimants or persons determined not eligible for unemployment or disability insurance benefits.
Knowledge of Local Office on-line Payment System (LOOPS) and Disability Automated Benefit System (DABS) procedures.
Knowledge of methods used to review and evaluate claims.
Knowledge of procedures used to conduct informal hearings. Ability to interpret laws, rules, and regulations, and apply them to specific situations.
Ability to communicate professionally with employers, union officials, insurance underwriters, examiners, and other officials both in person and by telephone.
Ability to analyze, interpret, and apply unemployment and temporary disability laws and operational procedures to specific situations.
Ability to perform mathematical calculations used to determine benefit rates for claimants.
Ability to analyze basic financial statements.
Ability to provide testimony at hearings and in court.
Ability to draft correspondence to claimants, employers, insurance companies, unions, or other public or private agencies to obtain information required to make determinations on claims.
Ability to prepare reports of findings, conclusions, analyses, and recommendations on depositions of claims.
Ability to provide guidance and instruction to clerical staff.
Ability to comprehend legal and medical terminology, problems, procedures, and practices used to analyze and interpret unemployment and disability insurance laws, and claims that arise under those laws.
Ability to interpret labor market data. Ability to analyze irregular and disputed claims to make determinations.
Ability to review and determine accuracy and acceptability of insurance policies and/or union bargaining agreements.
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
This job specification is applicable to the following title code(s) which
are different work week or work month and/or variants of the job class title:
