You are reading the State of New Jersey Job Descriptions. This is not a Job Vacancy Announcement.

Job Specification

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:

EDUCATION:

Graduation for an accredited college or university with a Bachelor's 
degree.

EXPERIENCE:

One (1) year of 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.

NOTE:  Applicants who do not possess the required education may 
substitute experience as indicated above on a year-for-year basis.

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 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.


This job specification is applicable to the following title code:
Job
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VariantState,
Local or
Common
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Service
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Local
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Note
56122SC3516N/AP15-

This job specification is for state government use only.
Salary range is only applicable to state government.
Local salaries are established by individual local jurisdictions.

3/14/2020