PRINCIPAL CLAIMS REVIEWER

Under the general supervision of a program manager, the incumbent will oversee the daily activities of the health insurance program and the claims review process. This role requires reviewing and processing complex claims to determine eligibility for premium assistance. The incumbent must contact various government agencies, providers, and recipients to gather necessary information for complex eligibility determinations, ensuring the timely analysis and processing of insurance claims.Additionally, the incumbent will supervise other claims reviewers and evaluate their performance; train new employees, monitor employees' utilization of benefits time, make recommendations around hiring, promoting, demoting, and/or disciplining of subordinates.

The incumbent must have expert knowledge of all state and federal regulations related to health insurance acquisition. They should be able to interpret and clarify these regulations in a way that is easy for the general public and customers to understand. The incumbent must remain updated on changes in federal and state regulations and promptly integrate these changes into the program as applicable.Additionally, the incumbent must be well-versed in public benefits programs available to New Jersey residents to effectively advise and assist applicants, guiding them to the best options applicable to them. They are required to assist coworkers, recipients and/or their representatives resolve complicated insurance coverage issues, and coordinate with insurance carriers to address and resolve coverage issues.

ONLY QUALIFIED APPLICANTS WILL BE CONTACTED FOR SCREENING/INTERVIEWS

The incumbent is required to contribute to program design, implementation, and evaluation. Specifically, provide suggestions for more effective claims processing methods; update program guidelines, requirements, policies, and procedures to align with new state or federal mandates and regulations; update training and marketing materials; provide education and technical support to the public and health care providers around program criteria and requirements; explaining the different coverage options available to applicants based on their needs.

THIS POSITION IS OPEN ONLY TO CURRENT STATE OF NEW JERSEY, DEPARTMENT OF HEALTH EMPLOYEES

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 in the evaluation and/or verification and eligibility determination of applications for financial or medical assistance, benefits or other health or human services programs, or in credit investigations for recovery of funds.

OR

Possession of a bachelor's degree from an accredited college or university; and three (3) years of the above-mentioned professional experience.

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 than employee mobility, is necessary to perform the essential duties of the position.