SENIOR CLAIMS ADJUDICATOR SPECIALIST DISABILITY DETERMINATIONS DEFINITION:
Under the direction of a designated supervisor or manager within the Division of Disability Determination Services (DDS), Department of Labor and workforce development (DOL), interviews claimants and makes technical eligibility determinations functioning as the single decision maker (SDM) with independent authority to make medical and non-medical decisions on complex claims and authorizes payment or notices of ineligibility for Social Security disability claims or performs public and professional outreach initiatives and other administrative liaison functions with the medical community providers of vocational rehabilitation services, applicant/claimant representatives or advocates, and various State resource providers for Social Security disability programs; does other related duties.
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, analyzes, develops and evaluates medical and vocational evidence within a complex legal framework to make determinations on the most complex and specialized claims for Social Security disability benefits.
Reviews, analyzes and evaluates medical, vocational, educational or legal evidence.
Develops records of all relevant and material facts.
Adjudicates claims.
Determines validity of claims.
Makes presumptive decisions and final on Social Security Act claims for disability benefits.
Makes recommendations and/or prepares determination.
Interview individuals for needed information which may include multiple telephone or face - to - face interview with applicant, their family or other representatives.
Informs claimants of denied claims and appeal rights.
Provides advice and guidance to adjudicative staff, medical sources and consultant staff, applicant/claimant advocates and representatives on medical, legal, vocational and technical aspects of claim development, documentation and determination.
Initiates predetermination contact with claimants to afford due process prior to rendering decisions unfavorable to claim payment.
Prepares oral or written consultations, case summations and rationales.
Consults with supervisors, medical sources and consultant staff, vocational resources experts, and others on complex case issues.
Consults with medical review physicians for guidance on medical issues relating to claims processing and decision making.
Conducts special projects and assignments to assess or improve efficiency and effectiveness of services.
Answers questions about application of regulations or policies.
Informs individuals of procedures necessary for completion of forms or applications.
Informs interested parties of case status.
Prepares decisions, notices, reports, correspondence and other written materials.
Updates and maintains references resources such as applicable statues, regulations, rulings, court decisions, medical and vocational references, Program Operational Manual (POMS), and internal data.
Consults with staff and procedural and policy issues and prepares specific policy interpretations and procedural applications.
Makes or recommends referrals to vocational rehabilitation or other State and local service organizations.
Prepares and maintains the claims files.
Performs public and professional outreach initiatives, with special emphasis on strengthening and increasing physician's participation in the documentation and evaluation of claims.
Conducts informative meetings and seminars.
Recruits physicians, psychologists and other treatment providers to serve as Disability Determination Services staff Medical Consultants and/or as Consultative Examiners (CE).
Maintains liaison with community and State resources that maintain evidence, providers of vocational rehabilitation services, or applicant/claimant representatives or advocates.
Contacts medical sources to resolve complaints by claimants, adjudicative staff or others and prepares reports and recommends actions.
Conducts workshops, seminars, or lectures for interested groups on various aspects of the Social Security Act disability programs.
Meets with groups at seminars, public meetings, or conventions as a representative of the agency.
Prepares articles for publication concerning Social Security Act disability programs.
Will be required to learn 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.
Seven (7) years of professional experience gathering and reviewing medical and/or vocational documentation and the investigation and analysis of claims to determine the eligibility or ineligibility for disability benefits, or closely related disability, medical, health insurance or adjusting agency experience, one (1) year of which shall have involved evaluation and adjudication of claims.
OR
Possession of a bachelor's degree from an accredited college or university; and three (3) years of the above-mentioned professional experience, one (1) year of which shall have invlolved evaluation and adjudication of claims.
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 employee mobility, is necessary to perform the essential duties of the position.
KNOWLEDGE AND ABILITIES:
Knowledge of disability determination theory and practice.
Knowledge of adult and childhood human anatomy, physiology, pathology; including the signs, symptoms and key laboratory findings associated with disease states.
Knowledge of the principles of psychiatry and psychology sufficient to determine the resulting degrees of physical and mental limitation.
Knowledge of the vocational factors used to assess the impact of age, education, vocational training, and past work experience.
Knowledge of basic interviewing techniques.
Knowledge of the methods for determining adequacy and value of evidence.
Knowledge of principles of report writing.
Knowledge of legal terminology.
Knowledge of medical terminology.
Ability to interpret and apply the statutes, regulations, rulings, and policies governing Social Security Act programs.
Ability to interpret and apply federal and state statutes, regulations and rules governing right to privacy and freedom of information.
Ability to interpret and apply federal and state statues, regulations and rules governing fraudulent claims.
Ability to interpret and apply federal and state statutes, regulations and rules governing similar fault and worker's compensation.
Ability to interpret and apply federal and state statues, regulations and rules governing social service and rehabilitation programs.
Ability to interpret and apply federal and state statures, regulations and rules governing medical assistance.
Ability to interpret and apply federal and state statues, regulations and rules governing the Internal Revenue Code, Railroad Retirement Act, and the Immigration and Naturalization Act.
Ability to interpret and apply statutes, regulations and rulings to the specific findings in Social Security Act disability program claims for benefits.
Ability to establish business relationships and work closely with medical sources and elicit medical information and documentation for case adjudication.
Ability to effectively communicate orally and in writing.
Ability to interact with various people who are differing situations.
Ability to collect data through questioning.
Ability to synthesize facts and relevant information to reach logical conclusions.
Ability to prepare clear, concise and sound reports, summaries and analyses containing findings, conclusions and recommendations.
Ability to investigate and resolve complaints regarding claims, Disability Determination Services procedures, or Consultative Examiners issues.
Ability to convey and summarize information in written format.
Ability to comprehend, interpret and analyze legal and medical findings.
Ability to comprehend, interpret and evaluate relevant information from various types of source materials.
Ability to maintain essential written and electronic records, files, and reference materials.
Ability to organize assigned work, prioritize and manage a caseload/workload.
Ability 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 as long as they can perform 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.
CODES: 26/P25 - 64964 MER 11/21/09
