A class incumbent is responsible for providing an in-depth and substantive review of adjudicated claims for Social Security Disability benefits and Supplemental Security Disability Income benefits.
Nature and Scope
Positions function under the general supervision of an administrative superior, and are responsible for evaluating the quality of investigations, adjudications and reports prepared by Disability Determination Adjudicators. Positions are responsible for conducting evaluation studies and managing an on-going review process. The review process involves a substantive appraisal of all aspects of case development and decision making for a representative sample of cases adjudicated by all levels of adjudicative staff. A significant aspect of this work involves analyzing all types of claims to determine whether there is sufficient documentation to support the determinations, whether the vocational aspects of the case are thoroughly investigated, and the accuracy or correctness of the decision. In addition, incumbents are involved in performing special program audits or reviews.
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.
Knowledge, Skills and Abilities
The intent of the listed knowledge, skills and abilities is to give a general indication of the core requirements for all positions in the class series; therefore, the KSA’s listed are not exhaustive or necessarily inclusive of the requirements of every position in the class.
Knowledge of medical terminology, body systems, disease treatment, examination procedures and medical specialty areas.
Knowledge of typical clinical medical findings as related to causes of physical and mental impairments, their treatments and side-effects, and implications for assessments of residual functional capacities.
Knowledge of physical and mental work demands, skill levels and transferable skills of occupations that commonly exist in the region and national economy.
Knowledge of the appeals and review processes related to disability adjudication.
Knowledge of Federal and State Law, rules and regulations dealing with or impacting on the social insurance disability programs provided by the Social Security Acts and the SSA.
Knowledge of the principles, theories, practices, policies and procedures of disability program management.
Knowledge of medical requirements, disease processes and corresponding testing and examination terminology involved in the SSDI and SSI programs.
Knowledge of the Social Security Administration’s electronic business process, including the informational and data systems.
Skill in providing objective, critical feedback to adjudicators and supervisors without being adversely influenced by strong rebuttal.
Skill in acquiring and analyzing disability data and to reach objective decisions that will keep the total DDS program in compliance with decisional accuracy standards.
Ability to interpret and apply complex disability determination laws, rules and regulations.
Ability to establish and maintain effective working relationships with claimants and physicians.
Ability to communicate clearly and concisely, both orally and in writing.
JOB REQUIREMENTS for Disability Determination Quality Assurance Senior Reviewer
Applicants must have education, training and/or experience demonstrating competence in each of the following areas:
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.