SENIOR CLAIMS EXAMINER UNEMPLOYMENT & DISABILITY INSURANCE
DEFINITION:
Under the general supervision of a supervisory official in the New Jersey Department of Labor and Workforce Development, makes or assists in making difficult decisions on complex and/or irregular unemployment or disability benefit claims; may assist Supervisor, Unemployment Benefits as a lead worker in a larger Unemployment Claims office (15 or more employees in a non-monetary unit); does other related duties as required.
NOTE: Appointments may be made to positions requiring bilingual skills.
56093C - 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:
Monitors unit workflow to prevent backlogs and ensure claimants are interviewed in the appropriate order.
Spot checks work often to maintain quality control; may recommend additional training if warranted.
May take the lead on establishing, collecting, and depositing refunds and oversee monetary adjustment of claims.
Prepares non-routine correspondence and memoranda in matters related to claims.
Provides assignments to support staff engaged in claims activities.
Answers and resolves inquiries and/or complaints concerning claims.
Trains employees on methods and procedures of processing claims.
Represents the agency at formal hearings and presents testimony.
Meets with claimants, employers, or other interested parties of legal representatives who personally visit the office to discuss or clarify claims.
Maintains a claims manual and disseminates related instructions to ensure new procedures are followed.
May make non-monetary and monetary determinations or process irregular, complex, and/or disputed claims.
Interprets and explains revised or newly enacted statutes, regulations, policies and procedures pertaining to the Unemployment or TDI Laws; recommends modifications in existing procedures where applicable.
Prepares clear, sound, accurate, and informative reports; recommends revisions in form letters and other materials used in correspondence.
Maintains essential records and files.
Arranges payments under subrogation for contested Workers' Compensation claims; investigates claimant's disability for Workers' Compensation liability; oversees the preparation of liens against Workers' Compensation awards, and determines whether the disability is connected to a former disability for which Workers' Compensation was paid.
Evaluates medical information on complex claims to resolve issues of eligibility.
Reviews all communications from claimants, employers, and other interested parties and their legal representatives regarding disputed claims.
Corresponds with interested parties explaining the Temporary Disability Insurance Law, Department regulations, and/or policy.
Reevaluates and resolves issues of disputed claims where possible and refers those that cannot be satisfied to the Appeal Tribunal.
Represents the Division of Temporary Disability and Family Leave Insurance at Appeal Tribunal hearings as necessary and reviews Appeal Tribunal decisions to determine if further appeal is warranted; maintains claims during and after the appeal process.
Resolves conflicts and duplication of benefits paid under laws for New Jersey disability, Workers' Compensation, Maritime, and Social Security disability benefits and other State and Federal benefits programs.
Resolves discrepancies in the more complex applications submitted for approval as a Private Plan and determines its accuracy, completeness, and acceptability under the law, and modifies plans to ensure compliance to law changes.
Recommends termination of private plans that do not meet qualifications and changes under the law.
Meets with Private Plan insurers, claimants, hospitals, and the union to obtain additional data to resolve issues with the administration of Private Plans.
Processes complex assignments as directed.
Determines benefit rights of claimants and authorizes payment for both unemployment and disability during unemployment claims.
Reviews existing unemployment claim conflicts and corresponds and instructs local office personnel on policy and Temporary Disability Insurance procedure.
Processes penalties for delinquent information requests.
Reviews and evaluates information requested from No-Fault Insurance Carriers and instructs personnel on following benefit reimbursement procedures.
Provides guidance to staff on processing online payments or initial and continued claims.
Ensures counter operations are properly staffed.
Provides necessary security and controls for pay orders and checks.
Audits and verifies bridge reports and ensures all data is entered accurately.
Prepares or oversees the preparation of reports such as monthly downtime, destroyed badge, signature machine, and Local Office Online Payment System (LOOPS) back-up.
Monitors scheduling of adjudication interview appointments to ensure timely first payment of benefits.
Conducts redetermination interviews on disputed initial determinations; issues redetermination to affirm, modify, or reverse initial determinations.
Prepares appeal forms and transmits appropriate local office claim file documents to the Appeal Tribunal.
Assists the Community Relations Manager in planning, assessing, and developing Community Outreach for Temporary Disability Insurance (TDI) and Family Leave Insurance (FLI).
Interprets and explains revised or newly-enacted TDI/FLI statutes, regulations, policies, or procedures at outreach events.
Participates in training staff, other agencies, and all other interested parties on TDI/FLI laws, policies, and procedures.
Develops and maintains effective working relationships with other agencies and other interested parties as it relates to bringing awareness to TDI/FLI programs.
Travels to various outreach events (conferences, meetings, etc.) to bring awareness of TDI/FLI programs, which can include weekends and evening hours. Responsible for traveling with and setting up outreach materials.
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.
Six (6) years of professional experience in the review, analysis, evaluation, and eligibility determination of claims in a public or private insurance company.
OR
Possession of a bachelor's degree from an accredited college or university; and two (2) years of the above-mentioned professional experience.
NOTE: "Professional experience" refers to work that is creative, analytical, evaluative, and interpretive; requires a range and depth of specialized knowledge of the profession's principles, concepts, theories, and practices; and is performed with the authority to act according to one's own judgment 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.
Knowledge of community outreach planning and development.
Knowledge of operation and functions of private insurance company claims and underwriting departments.
Knowledge of theories, practices, and methods for employee training and staff development.
Knowledge of the function, purpose, and operation of social insurance programs in general, and the Division of Temporary Disability and Family Leave Insurance in particular.
Knowledge of the function and operating procedures of the offices of Private Plan hearing officers.
Ability to interpret, apply, and keep current with State and Federal laws, rules, and regulations applicable to unit operations.
Ability to analyze, interpret, and apply unemployment and temporary disability laws and operational procedures to specific situations.
Ability to conduct informal hearings.
Ability to process claims.
Ability to function as a lead worker. Ability to testify as a witness for the State.
Ability to comprehend legal and medical terminology, problems, and practices of disability and unemployment claims.
Ability to analyze basic financial statements.
Ability to review and interpret documents submitted by claimants.
Ability to perform mathematical calculations used in determining the benefit rate for claimants and/or benefit rates to be provided by private plans.
Ability to handle and resolve complaints from the public.
Ability to collect, record, and deposit cash refunds.
Ability to coordinate Claims Unit activities with other office units.
Ability to instruct and guide employees on methods and procedures used for processing claims.
Ability to train staff, agencies, and others on TDI/FLI laws, policies, and procedures.
Ability to oversee unit operations in the manager's absence.
Ability to review claims, resolve complaints and/or take appropriate action.
Ability to establish and maintain cooperative working relationships with co-workers, supervisors, officials, and the public.
Ability to prepare correspondence.
Ability to prepare reports containing findings, conclusions, analyses and recommendations on depositions of claims or acceptability of private plans or other related matters.
Ability to examine and interpret employer, doctor, union, and insurer records with reference to all operations index of the TDI law.
Ability to collect, analyze, and interpret reports of claim activities containing findings, conclusions, and recommendations.
Ability to collect, analyze, and interpret facts of disputed claims.
Ability to oversee maintenance of essential 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.
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:
