JOB TITLE: DISABILITY CLAIMS ADJUDICATOR

JOB CODE: 45080

SERIES NATURE OF WORK: The Disability Claims Adjudicator job series describes work determining eligiblity for federal disability benefits.

DEFINITION: This is advanced technical work in the adjudication of disability claims.

An employee in this job reviews disability claims and renders decisions based on documentation received, the potential for vocational rehabilitation, and other applicable considerations determined by federal law and federal and state regulations and standards. Work involves obtaining and evaluating medical and other evidence to use as a basis for decisions on initial or continuing eligibility for disability claims benefits; conferring with medical and other consultants to resolve complex issues related to disability claims; developing case information to serve as the basis for decisions by hearing officers and Administrative Law Judges; and conducting claimant conferences to ensure due process. Work is performed within a Quality Assurance Unit conducting reviews of decisions on a sample basis, or reviewing claims to continue or cease benefits to claimants currently receiving benefits; in a Medical Services Unit assisting in the development and maintenance of ongoing relationships with medical services providers and resolving medical relations problems; or in a Disability Services Unit developing and assessing medical evidence, maintaining claimant contact, and proposing decisions for review by medical staff. Work is performed independently in accordance with applicable laws, regulations, and standards, and is reviewed by an administrative supervisor through conferences and reports.

   DISTINGUISHING CHARACTERISTICS:

     • Work is distinguished from the lower-level job by the responsibility for independently obtaining and evaluating applicable documentation and rendering decisions on claimant eligibility.

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.)

• Reviews representative samples of claims to determine the correctness of the decision, the completeness of claim development and documentation, and the appropriateness of claim development techniques.

• Completes a data sheet on each claim reviewed and documents reasoning for claims where the decision is found to be incorrect or the documentation is incomplete.

• Reviews high risk claims identified through analyses of sample case review data, central and regional office feedback, supervisory and management input, and special study data to ensure the decisions are correct and identify possible trends.

• Performs a wide variety of special studies and projects to measure and evaluate the effectiveness of existing procedures, work flows, and policies and recommends changes and additions.

• Reviews Continuing Disability Review (CDR) claims to determine if claimants already receiving benefits should continue to receive them based on Social Security regulations.

• Contacts hospitals, private physicians, or SSA contracted medical facilities to identify potential medical consultative examiners and explain agency requirements, fees, and necessary report content.

• Collects data from claimants, medical suppliers, hospitals, and public and private agencies in sensitive or complex situations to make disability determinations.

• Receives and investigates complaints and problems reported from the medical provider community regarding fees, scheduling, and program policies and procedures.

• Receives and investigates complaints and problems reported from professional staff regarding issues in the medical provider community, such as timeliness and content of reports, and overbilling and scheduling irregularities; and from claimants regarding consultative examiner services.

• Obtains, reviews, and analyzes medical evidence of record and consultative examination reports to determine whether or not they comprise a sufficient record to support a disability determination and prepares a narrative rationale based on Social Security regulations.

• Prepares content for notice letters to claimants to explain the basis for unfavorable determinations.

• Maintains effective and cooperative working relationships with claimants, staff members, the medical community, and private agencies to secure information to adjudicate disability claims and refer claimants for other services.

• Communicates with claimants, claimants’ representatives, attorneys, physicians, hospital personnel, and other medical sources to obtain evidence necessary to properly develop disability claims.

• Conducts conferences with claimants and their representative or attorney to provide information regarding the basis for the pending decision, acquire additional evidence, and discuss steps to complete consideration of the claim as required by due process.

• Completes reports regarding workflow, claims completion rates, and expenditures.

• Maintains and updates documents such as federal and state policy and procedures manuals.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of disability claim adjudication principles and practices.

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

• Knowledge of the Social Security Act and related laws, federal regulations, federal vocational resources, and policies concerning disability programs.

• Knowledge of basic medical concepts and terminology.

• 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 use and functionality of Microsoft Office Suite software.

• Ability to accurately and consistently apply disability claim adjudication principles and practices.

• Ability to organize, analyze, and evaluate medical and non-medical evidence and make sound technical decisions.

• Ability to write clear, accurate, and concise reports of findings, conversations, conferences, and medical information.

• Ability to maintain records and prepare reports.

• 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)

• Successful completion of the Disability Claims Adjudicator Trainee program (commonwealth title);

or

• One year 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 one year of experience in the adjudication of Social Security disability claims.