Disability Determination Quality Assurance Senior Reviewer

State of Delaware • Dover, DE

2d

About The Position

The incumbent reports to the Disability Quality Assurance Manager and is responsible for conducting reviews of disability claims processed by adjudicators. The Reviewer identifies deficiencies in case work, documents the findings, cites the policies and provides next step action to bring the claim into compliance. The position is responsible for maintaining a small caseload. Lastly, the incumbent will act as the DDS liaison for reporting fraud, and similar fraud allegations to the Social Security Administration. Essential Functions Essential functions are fundamental, core functions common to all positions in the class series and are not intended to be an exhaustive list of all job duties for any one position in the class. Since class specifications are descriptive and not restrictive, incumbents can complete job duties of similar kind not specifically listed here. Reviews a sample of disability claims to determine the adequacy of case development, the documentation of determinations, and the accuracy of decisions based upon the facts and program guidelines in order to monitor the quality of the adjudication process. Prepares written reports identifying and describing findings which include decisional and significant technical deficiencies in the adjudication process and the resulting reports for the purpose of providing direction to adjudicators to make corrective action in the case decision. Conducts a review of corrective actions and final case decision of returned cases upon completion of remedial action to assure accurate completion of case adjudication. Identifies substantive and procedural issues with adjudicator and medical consultant working relationships and information exchanges; analyzes delays in operational work flow and identifies training needs and problems. Participates in special studies and case reviews; reports findings to the Quality Assurance Administrator for administrative action. Assists with the total program evaluation and identifies weaknesses and deficiencies in the electronic case processing systems, quality and integration of medical consultant assessments, all support functions, and basic claim adjudication processes. Assists in providing training to adjudicators and medical consultants in deficiency areas (e.g., claim processing operations) to correct problems. Reviews claims returned by federal components (Office of Disability Operations/Disability Quality Board) noting trends in federal returns; compares these returns to deficiencies noted internally in order to determine if Quality Assurance is consistent with federal review and return policy. May assist the Quality Assurance Administrator in preparing monthly and quarterly reports of Quality Assurance findings to the Deputy Director.

Requirements

• Three years experience in evaluating disability claims and making disability determinations.
• Six months experience in disability adjudication appeal and review process.
• Six months experience in interpreting Social Security Administration laws, rules, regulations, standards, policies and procedures.
• Six months experience in program evaluation which includes evaluating programs and services to identify problems, determine compliance and evaluate the effectiveness and efficiency to ensure program goals and overall objectives are met.
• Six months experience in recommending alternatives, improvements, courses of action and other changes based on findings.
• Six months experience in narrative report writing.

Responsibilities

• Reviews a sample of disability claims to determine the adequacy of case development, the documentation of determinations, and the accuracy of decisions based upon the facts and program guidelines in order to monitor the quality of the adjudication process.
• Prepares written reports identifying and describing findings which include decisional and significant technical deficiencies in the adjudication process and the resulting reports for the purpose of providing direction to adjudicators to make corrective action in the case decision.
• Conducts a review of corrective actions and final case decision of returned cases upon completion of remedial action to assure accurate completion of case adjudication.
• Identifies substantive and procedural issues with adjudicator and medical consultant working relationships and information exchanges; analyzes delays in operational work flow and identifies training needs and problems.
• Participates in special studies and case reviews; reports findings to the Quality Assurance Administrator for administrative action.
• Assists with the total program evaluation and identifies weaknesses and deficiencies in the electronic case processing systems, quality and integration of medical consultant assessments, all support functions, and basic claim adjudication processes.
• Assists in providing training to adjudicators and medical consultants in deficiency areas (e.g., claim processing operations) to correct problems.
• Reviews claims returned by federal components (Office of Disability Operations/Disability Quality Board) noting trends in federal returns; compares these returns to deficiencies noted internally in order to determine if Quality Assurance is consistent with federal review and return policy.
• May assist the Quality Assurance Administrator in preparing monthly and quarterly reports of Quality Assurance findings to the Deputy Director.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed