CLAIMS INVESTIGATOR 2
DEFINITION:
Under the limited supervision of a Claims Investigator 3, Claims Investigator 4, or other supervisory official in a state or local government department or agency, conducts the more complex and/or sensitive investigations and evaluations; recommends settlements or payment of claims arising out of workers compensation, negligence, tort and/or claims for ownership of abandoned real, personal, tangible and non-tangible property accrued to the state, other claims involving state/local employees and/or state/local owned property, as well as other types of negligence or tort claims made against the state; may take the lead over investigative and other staff involved in the work of the unit; investigates fraud and disaster-related claims; 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:
As assigned, investigates and obtains the essential information required in connection with claims arising out of workers compensation, tort, contract, negligence, and personnel matters involving state/local employees and state/local owned property, as well as other types of negligence or tort claims encountered by the state.
As assigned, investigates and obtains the essential information required in connection with claims arising from abandoned real, personal, tangible and non-tangible property that has accrued to the state.
Examines the more difficult and complex claims for authenticity, authorizes payment of benefits, and recommends fraud investigations as needed.
Reviews the more difficult and complex claims that are served by writs to the State of New Jersey by the Division of Taxation to levy on specific individuals in the collection of funds being held by the Unclaimed Property Administration.
As assigned, conducts fraud investigations for workers compensation, tort, contract, negligence, and/or unclaimed property claims.
As assigned, performs the investigation and review of traumatic injury claims.
Analyzes the impact of comorbidities (pre-existing conditions) and psychosocial issues such as post-traumatic stress disorder.
Performs the investigation and review of disaster-related claims, in accordance with Federal Emergency Management Agency (FEMA) and New Jersey Office of Emergency Management policies, practices, and procedures.
Contacts debtors, attorneys, and representatives of insurance companies with reference to settlement of negligence claims.
Contacts representatives of claimants such as attorneys, administrators, executors, and guardians in order to resolve claims.
Visits and interviews physicians, professional specialists, state/local employees, police officers, and other witnesses and records their testimony.
Visits scenes of accidents, makes sketches, takes photographs, and obtains police reports and medical and other data needed in the processing of all claims made by and against the state, which is to be used, when necessary, in litigated cases involving property damage claims; assists in accident prevention analysis to determine if safety training is required.
As assigned, participates in the review of Medicare’s conditional payments made on behalf of injured parties.
Obtains X-rays and medical reports, makes abstracts of hospital and other records, and compiles other data needed in the preparation and trial of cases.
Attends formal and informal hearings, meetings, and conferences, as required.
Develops working knowledge of new and emerging types of unclaimed property, and may assist in training Claims Investigators of same or lower grade.
May participate in public outreach activities to promote awareness to the citizenry about the availability of unclaimed property.
Processes assigned cases from the onset to payment of the claim.
Recommends settlements in accordance with prescribed policies/limits.
Prepares summaries, reports, and recommendations for the use of the supervisor.
Ascertains facts, collects evidence, receives testimony, and explains basic procedures and regulations.
Locates pertinent cases, claims, and/or precedents in the case files of the investigative bureau or unit, and prepares summaries of such material.
Refers unusual and difficult problems to the supervisor.
May function in a lead capacity over staff.
Provides guidance and assistance to lower grade Claims Investigators and others as required.
Makes the preliminary arrangements for the physical and medical examinations of injured state employees as required.
Attends court hearings in connection with accidents involving state property, equipment, or personal injury to state employees.
When required, acts as a witness in court proceedings.
Prepares clear, sound, accurate, and informative reports of claim matters containing findings, conclusions, and recommendations.
Maintains records and files and reports of the bureau or unit.
Will be required to learn how to utilize various types of electronic and/or manual recording and computerized 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 workers compensation, negligence or claims investigation.
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 appropriate laws, rules, regulations, standards, policies, and procedures of the investigative bureau or unit assigned as they apply to claims work.
Knowledge of negligence law, tort law, contract law, and rules of evidence, or abandoned property law.
Knowledge of the medical and/or legal terms commonly used in claims work, including terminology specific to the Medicare program.
Knowledge of the techniques of interviewing and their application to specific claims situations.
Knowledge of the problems likely to be encountered in investigation and claims processing work.
Knowledge of anti-fraud methodologies, investigation techniques, and software.
Knowledge of the claims that are served by writs to the State of New Jersey by the Division of Taxation, to levy on specific individuals in the collection of funds.
If assigned to the Division of Risk Management, knowledge of Title 34 (the Workers’ Compensation Statute), and Title 59 (the Tort Claims Act).
If assigned to the Unclaimed Property Administration, knowledge of Title 46 of the New Jersey Statutes and Title 17:18 of the New Jersey Administrative Code.
Ability to apply the regulations, policies, and procedures of the investigative bureau or unit in the processing of claims against the state for injury and/or damage.
Ability to apply regulations, policies, and procedures of the abandoned property unit in the processing of claims.
Ability to understand, analyze, and interpret basic law and regulations to persons of varying education, economic, and ethnic backgrounds.
Ability to organize assigned investigations and/or claims work and develop effective work methods.
Ability to locate and secure information, select and summarize pertinent data, and prepare clear, sound, accurate, and informative reports of investigations and claims matters which shall include documentary evidence of varied types.
Ability to confer with physicians and other members of the medical profession, hospital and clinic staff, police officers, claimants, attorneys, key witnesses, and others and to obtain such oral and other testimony and evidence, including copies of medical reports and records, as required by the particular case.
Ability to take the lead over claims investigations and others involved in the work of the unit.
Ability to work with external stakeholders, including Medicare, the Federal Emergency Management Agency, and the New Jersey Office of Emergency Management, on various types of claims.
Ability to continuously monitor claims for indicators of fraud.
Ability to participate in outreach activities.
Ability to acquire knowledge about new and emerging types of unclaimed property, and to train lower-ranking employees.
Ability to review and analyze case records, testimony, statements of witnesses, and other information.
Ability to locate potential sources of information.
Ability to work effectively with claimants, debtors, professional witnesses, police officers, insurance company representatives, attorneys, estate representatives, and the public in connection with the work of the bureau or unit.
Ability to act as a witness and to present testimony in court actions.
Ability to prepare detailed correspondence pertaining to the claims work of the bureau or unit.
Ability to prepare clear, sound, accurate, and informative reports and case summaries containing findings, conclusions, and recommendations.
Ability to maintain essential records, files, and reports of the bureau or unit.
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 the 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:
