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State of Washington Classified Job Specification

DDS ADJUDICATOR 5

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DDS ADJUDICATOR 5
168L
Category: Financial Services

Class Series Concept

See DDS Adjudicator 1.

Definition

This is the supervisory or expert level of the series. 

Distinguishing Characteristics

Positions have shared statewide or regional responsibility in at least one of the following areas: 

  • Supervision: Supervises a unit of DDS Adjudicators;
  • Quality assurance: Reviews decisions made by the DDS Adjudicator to ensure accurate and policy compliant decisions;
  • Disability hearings: Conducts case review and hearings for claimants whose benefits have been ceased after a Continuing Disability Review;
  • Professional relations: Provides education to the medical and professional community about the disability program requirements and has oversight of contracted Consultative Examiners and DDDS contracts;
  • Training: Provides introductory and ongoing training for DDS Adjudicators and contracted Medical Consultants;
  • Cooperative disability investigations: Develops documentation and provides program requirements used in investigations, discovery and prosecution of Social Security fraud and similar fault.
Positions in this class are considered experts and have advanced knowledge and skills in all aspects of federal laws and policies related to disability claims adjudication, medical, vocational and program/policy.

Typical Work

Supervises a work unit of disability adjudicators and support personnel; 

Monitors and evaluates the performance of subordinates; 

Maintains and coordinates liaison activities with the Social Security field offices and Community Service offices in assigned geographical areas; 

Provides medical and policy review on all case decisions by DDS adjudicators in-training;

Reviews cases for appropriate documentation, processing procedures and decision policy; samples cases to assure that quality standards are met; 

Audits the quality of case development; and analysis and advises adjudicators and medical consultants on appropriate documentation, medical and vocational development, processes and procedures and policy decisions; samples cases to assure that quality standards are met; 

Manages, oversees and participates in recruitment, staff interview processes, and selection in hiring;

Resolves staff grievances and issues and takes corrective action if necessary;

Works directly with DDDS Executive Leadership in problem solving and providing expertise regarding case processing and performance management; Develops and carries out specialized studies, analyses and reports; 

May act as a liaison for the contracted Medical Consultants (MC), monitoring and facilitating the MC work, maintaining the MC Business Process, overseeing MC work schedules, desk coverage, timekeeper and IT issues, compiling and reporting MC statistics to Executive Leadership Team, monitor, direct and report on the Second Opinion Process;  works with other State DDS offices and Regional Social Security Administration offices coordinating work transfer and MC review quality assurance;

Reviews, recommends changes, and implements Social Security/SSI federal laws and regulations;

Prepares summary and status reports; 

Participates in developing and maintaining appropriate and consistent statewide policies, procedures and standards; 

Recruits, trains and provides oversight of physicians and mental health professionals to provide consultative medical/psychological exams and ancillary services including labs and x-rays; 

Analyze and research medical tests and equipment to determine which tests are policy compliant;

Determines appropriate exam types and cost reimbursement for consultative evaluations;

Coordinates and maintains effective relationships with the medical community and other outside resources; responds to inquiries and complaints from the medical community and clients; 

Plans and develops seminars, publications and training for providers; 

Investigates and resolves problems between the DDS and consultative examination providers; 

Coordinates the participation of beneficiaries, attorneys, other representatives and witnesses involved in the hearing process; 

Conducts face-to-face evidentiary hearings and acts as a sole decision-maker on specialized categories of appeal level claims; 

May represent the DDDS as an expert witness at DSHS Fair Hearings and Federal Court;

Develops training manuals and trains on program policies and procedures and systems software; 

Utilizes state and agency regulations and guidelines to develop, vet and execute contracts including suspension of contract and/or determining if contractors meet contract performance requirements and make rationale for termination;

Reviews and prepares decisions on claims for possible fraud and similar fault, writing case analysis and suggested area for investigation for the Office of Inspector General; 

Collaborates with Office of Inspector General and in the cooperative disability investigations process and decision-making;

Performs other work as required.

Knowledge and Abilities

Knowledge of:  the Social Security/SSI disability program statues, regulations, policies and common use law pertaining to disability evaluation; medical terms, human anatomy and physiology, psychiatric terms, common drugs, common treatment modalities and their implications; common occupations and their physical and mental skill requirements; effective supervisory and management principles and techniques; review methods and statistical analysis techniques. 

Ability to:  Review and analyze Social Security/SSI cases for sufficiency of documentation and correctness of decision; speak effectively in a public setting; write analysis of complex medical evidence and provide reasoned conclusions; write non-technical reports describing medical issues to lay persons; analyze complex medical, vocational and programmatic data and provide reasoned conclusions; discuss medical requirements with staff physicians; prepare and defend a timely and accurate decision that is equitable and in accordance with the law; establish and maintain effective working relationships with subordinates, colleagues, supervisors, claimants, physicians, and the general public.

Legal Requirement(s)

There may be instances where individual positions must have additional licenses or certification. It is the employer’s responsibility to ensure the appropriate licenses/certifications are obtained for each position.

Desirable Qualifications

A Bachelor's degree

OR  

Professional experience working with disability, medical or insurance claims adjudication or investigation, health care, unemployment, workers compensation, social services, or related field will substitute, year for year, for education. 

AND

Four years of recent experience as an adjudicator of Social Security Disability insurance. Must have successful experience adjudicating all claim types.

Note: Recent years of experience must be gained within four years of application.

Class Specification History

Effective May 1, 1963
Adopted June 26, 1964
Revised March 13, 1972 Revises definition and minimum qualifications
Revised May 21, 1973 Revises definition, adds distinguishing characteristics, and title change (formerly OASI Adjudicator 3)
Revised April 18, 1974 Revises minimum qualifications
Revised August 26, 1977 Revises distinguishing characteristics
Revised September 28, 1977 Revises distinguishing characteristics
Revised May 12, 1978 Revises distinguishing characteristics
Revised March 9, 1990 Revises definition and minimum qualifications, deletes distinguishing characteristics, and title change (formerly OASDHI Adjudicator 3)
Revised November 13, 2000: Revises salary, title change (formerly ODI Adjudication Supervisor/Specialist), definition and minimum qualifications
New class code: (formerly 47800) effective July 1, 2007
(08/25/2009) Removed OR Equivalent education/experience language from desirable qualifications.
Revised salary range, definition, distinguishing characteristics, typical work, knowledge and abilities and desirable qualifications; adopted June 30, 2017; effective July 1, 2017.
Revised salary adjustment, title, definition, distinguishing characteristics, typical work, and desirable qualifications; adopted June 13, 2019; effective July 1, 2019.

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