JOB TITLE: DISABILITY FRAUD OFFICER

JOB CODE: 45100

DEFINITION: This is professional fraud detection and training work in the identification and resolution of program vulnerabilities and the deterrence, reduction, and elimination of fraud, abuse, collusion, and other illegal conduct involving the Pennsylvania Social Security disability claims program.

The employee in this job receives fraud referrals, initiates investigations into alleged violations of the Social Security Act and other federal or state disability regulations and policies, and provides direction to Disability Claims Adjudicators in the identification and prevention of fraud in the disability claims process. Work involves planning, organizing, and coordinating investigations to ascertain facts and obtain evidence of fraudulent activity and conduct related to the disability claims program; preparing reports to document investigation results and prove or disprove fraud, criminal activity, and collusion; and making recommendations to resolve program vulnerabilities and substantiated cases of fraud, criminal activity, or collusion through criminal prosecution, the recoupment of program funds, or the assessment of program penalties. Work includes developing and delivering training programs to ensure consistency in the detection, identification, and referral of suspected cases of fraud to the fraud investigation unit. Work is performed with considerable independence and is subject to review by a Disability Adjudication Program Manager through conferences, investigative reports, and evaluation of program effectiveness.

EXAMPLES OF WORK: (NOTE: The examples of work are representative of the work, but every position classified to this job may not perform all examples of work listed. Conversely, this is not an all-inclusive list of work examples.)

• Plans and organizes investigations into suspected cases of fraud, waste, abuse, collusion, and illegal conduct involving disability claims recipients, department employees, physicians, lawyers, or other third parties.

• Communicates with federal and state disability program personnel and investigators to coordinate investigations, enhance the fraud referral and detection processes, and develop recommendations for the establishment of program policies and procedures to resolve fraudulent activity and programmatic vulnerabilities in the disability claims program.

• Determines which cases should be investigated based on the disability determination process and program policies, procedures, goals, and objectives.

• Applies technical program knowledge to determine the validity of fraud referrals and the feasibility of investigations into suspected cases of disability fraud.

• Performs investigative functions to gather evidence, such as interviewing claimants, employers, physicians, lawyers, and others, and reviews and analyzes claims records, bank statements, and medical documentation.

• Recommends and coordinates surveillance and other intelligence activities to capture and substantiate acts of disability fraud and abuse.

• Recommends the procurement of services to develop evidence, including the purchase of consultative exams, independent medical examinations, and laboratory testing.

• Develops, maintains, and delivers training presentations and courses to educate disability determination staff on the proper methods and procedures used to detect, identify, and make referrals of suspected cases of disability program fraud and abuse.

• Provides guidance to disability determination staff in the interpretation of medical sources and information, vocational issues, and adjudication practices to facilitate the detection and identification of patterns of fraud, abuse, collusion, and other illegal conduct involving the disability claims program.

• Collects, compiles, evaluates, and develops evidence and prepares it for orderly presentation.

• Prepares a detailed report of each investigation to convey findings of fraudulent activities or lack thereof.

• Drafts referrals for the recoupent of overpaid or erroneously issued disability payments and the prosecution of substantiated cases of disability fraud.

• Recommends changes in agency administrative operations to prevent future fraudulent activity.

• Confers with federal and state government agency officials concerning the conduct, scope, and resolution of investigations, to include the processes of filing criminal and civil charges.

• Attends training sessions provided by the Social Security Administration on program or policy changes.

• Performs the full range of supervisory duties.

• Employees in this job may participate in the performance of subordinates’ work consistent with operational or organizational requirements.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of Social Security disability claim adjudication principles and practices.

• Knowledge of Social Security disability claim development principles, methods, and techniques.

• Knowledge of the Social Security Act and related federal regulations and policies concerning state level disability programs.

• Knowledge of medical concepts and terminology applicable to the disability determination process.

• Knowledge of physical and mental impairments and their effects on work-related functions.

• Knowledge of the physical demands and skill requirements of occupations.

• Knowledge of the techniques used in evaluating medical and non-medical evidence.

• Ability to read and interpret written materials.

• Ability to communicate effectively in writing.

• Ability to communicate effectively orally.

• Ability to establish and maintain effective working relationships.

MINIMUM EXPERIENCE AND TRAINING: (NOTE: Based on the Entry Level Knowledges, Skills, and Abilities)

• Two years as a Disability Claims Adjudicator (commonwealth title);

or

• Two years of technical experience in the adjudication of Social Security disability claims and a bachelor’s degree;

or

• An equivalent combination of experience and training that includes two years of technical experience in the adjudication of Social Security disability claims.