SENIOR MEDICAL CLAIMS REVIEW CLERK
New Jersey treats Senior Medical Claims Review Clerk as a competitive-class job, so the gate is an examination and the ranked list it produces rather than a direct offer.
Eligibility comes down to 4 years of relevant experience. The FY2027 range lands between $44,750 and $64,522.
How to apply
This title is filled by competitive examination.
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See where to apply for this title →Official job specification
The text below is the official specification published by the New Jersey Civil Service Commission. The plain-language summary and analysis above are derived from it by NJ Civil Service Navigator. Source: the official specification page at NJ CSC.
Definition
Under the direction of a supervisor in the Division of Medical Assistance and Health Services, Department of Human Services, or in a local government agency or institution, assists in supervising the review and audit of medical claims in compliance with the policies, procedures, and allowances of the New Jersey Health Services Program; handles claims requiring personal contact; duties other related duties.
Examples of work
- Assigns work to and assists in the instruction of Medical Claims Review Clerks.
- Supervises the processing of provider requests for recipient re- examinations in accordance with Program guidelines.
- Resolves provider and recipient inquiries and complaints.
- Resolves provider payment problems through review of pertinent information and data.
- Gathers pertinent information for requests; identifies and refers discrepancies to the supervisor for appropriate action.
- Evaluates and resolves contractor claims.
- Supervises the review of claims submitted to ensure the provider's adherence to program rules and regulations.
- Contacts recipients to determine the authenticity of provider's requests.
- Verifies the accuracy and authenticity of laboratory invoices submitted by providers.
- Prepares and maintains records and files.
- Will be required to learn to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.
Experience
Four (4) years of experience in processing medical or health claims.
License
Appointees must possess, or be able to obtain, a driver's license valid in New Jersey only if the operation of a vehicle, rather than employee mobility, is necessary to perform essential of the position.
Knowledge, skills and abilities
- Knowledge of the methods used to review and evaluate medical claims.
- Ability to provide assignments and instruction to staff and review work performance.
- Ability to review provider claims and laboratory invoices for accuracy and authenticity.
- Ability to read and interpret regulations and apply them to specific situations.
- Ability to resolve provider and recipient inquiries and complaints.
- Ability to interpret information and data from computer-generated reports.
- Ability to detect instances of program abuse or over-utilization.
- Ability to prepare and maintain files and records.
- Ability to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.
- Ability to read, write, speak, understand, and communicate in English sufficiently to perform this position's duties. American Sign Language or Braille also may be considered as acceptable forms of communication.
- Persons with mental or physical disabilities are eligible as long as they can perform essential functions of the job with or without reasonable accommodation. If the accommodation cannot be made because it would cause the employer undue hardship, such persons may not be eligible.
Note
The work examples for this title are illustrative only, and not intended to be all-inclusive. A particular position using this title may not perform all duties listed in this job specification.