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Social Insurance Specialists

Significant Points

This job series includes positions that involve managing, supervising, or performing work concerned with the administration and operation of national social insurance and need-based benefit programs. This includes: (1) assisting people in establishing entitlement and receiving benefits; (2) adjudicating, authorizing, or reconsidering claims for benefits; (3) representing programs before the general public and providing information through various media; (4) studying operations, case processing, systems operations, methods, and procedures to improve the operation and delivery of programs and to assess the integrity and quality of program operations; (5) interpreting program requirements and formulating policies, procedures, methods, work aids, technical guides, and other reference material for program operations; and (6) preparing training materials and providing training to staff.

Nature of the Work

Social insurance programs touch the lives of all Americans at various times, often in times of crisis, need, or distress. The provisions that govern these programs are extensive, complex, and subject to frequent amendment. Employees who perform work described in this part of the standard provide the link between the people and the law that enables them to receive retirement and survivors insurance, disability insurance, and supplemental income. All positions in this series require knowledge sufficient to adjudicate, authorize, or reconsider claims for benefits as described below.

1. Adjudicating the claim--This is determining that the claimant is or is not eligible and entitled to the benefits for which he/she filed a claim. The employee: (a) determines that all requirements relating to eligibility and entitlement for benefits are met; (b) develops additional evidence when appropriate; c) determines the highest benefit rate to which the claimant is entitled; (d) writes justifications or special determinations related to the claim, as necessary; and (e) prepares and certifies determinations of award or disallowance of claims.

2. Authorizing the claim--This is exercising the agency's authority to allow or disallow the claim. This authority may rest in the same employee who initially adjudicates the claim or may be assigned to employees in other types of positions.

3. Reconsidering the claim--This is a thorough and independent reexamination of the claim, either because the claimant, or the agency on its own motion, has requested it. A reconsideration is the ultimate step in the claims examining process prior to a formal appeal by the claimant. It includes further development of facts and evidence as well as a review of the adjudication and authorization decisions. A reconsideration results in affirming or reversing the determination in whole or in part.

Social Insurance Specialist, GS-0105-09

The work requires knowledge of social insurance laws, programs, practices, methods, and techniques sufficient to perform assignments independently using procedures that are conventional and apply to most situations.

Employees use this knowledge to adjudicate claims for benefits under the retirement and survivors insurance, supplemental income, or the nonmedical aspects of the disability insurance benefit programs. Issues are clear and the policies, procedures, and governing provisions are directly applicable.

The work requires:

-- Knowledge of the various titles of the Social Security Act, the Internal Revenue Code, other public laws and regulations that apply to or affect the operation of social insurance programs, and the policies and procedures described in operating instructions for these programs;

-- Knowledge of other Federal and State benefit, tax, citizenship, veterans, and welfare programs and, as appropriate, international legal agreements, other public, private, and nonprofit retirement programs, and other programs that interrelate with social insurance programs;

-- Knowledge of the agency's organization and operations and familiarity with the work processes of organizations with which the agency must coordinate its operations;

-- Knowledge of applicable State laws on validity of marriage, divorce, descent, and distribution of property as they affect eligibility for social insurance benefits;

-- Knowledge of the agency's integrated automated case processing systems and skill in using the systems' input and output methodology, forms, and data;

-- Skill in interpreting various legal documents and medical reports and in evaluating the age and authenticity of evidence submitted as proof of factors of eligibility;

-- Skill in interpreting, applying, and explaining provisions of the social insurance laws and operating instructions orally and in writing to people of varying abilities of comprehension, levels of language familiarity, and degrees of interest in situations that are sometimes stressful; and

-- Skill in independent analysis and problem solving to:

develop appropriate information and evidence;
analyze numerous facts, evidence, and allegations to determine their accuracy and applicability;
reach timely and correct conclusions; and
express decisions clearly and concisely in both written and oral form.

Illustration:

-- Conducts interviews to obtain, clarify, and verify information about initial and continuing eligibility for retirement, survivors, disability, and health insurance benefits, and eligibility for supplemental security income including State supplements. Adjudicates claims for benefits and eligibility for one or more of these programs. Determines if applicants for, or recipients of, disability insurance are engaging in substantial gainful activity. Approves the selection of representative payees for individuals unable to handle their own benefits in complex and contested situations. Determines whether income is wages or self-employment income and whether it is covered income under governing provisions.

Social Insurance Specialist, GS-0105-11

The work requires a comprehensive knowledge of social insurance programs of sufficient breadth or intensity to perform the complete range of functions within an assigned area without limitation as to type of case or degree of difficulty, to analyze and correct systems and operational problems, or to develop new or modified systems, methods, policies, procedures, and other guidelines to support program operations.

Employees use this knowledge to resolve cases in which issues, circumstances, and/or governing provisions require advanced technical proficiency; to decide special entitlement matters; to review and improve operational and systemic quality; and to perform similar program-related functions. Some employees use lay medical and vocational program knowledge to review and authorize State agency determinations of medical impairments or to reconsider determinations of disability for hard to prove physical and mental conditions. Other employees use knowledge to prepare congressional or other sensitive correspondence on complex, delicate, or highly contested case matters and determinations.

Illustrations:

-- Adjudicates and authorizes claims for benefits and eligibility for one or more social insurance programs without further review. Decides and takes appropriate action on all issues without regard to difficulty. Conducts supplemental income program case reviews and conferences to reconsider decisions affecting an individual's eligibility or amount of benefit. Identifies and investigates questionable situations involving entitlement, continuing benefit, or improper use of Social Security numbers to decide whether fraud prosecution should be recommended.

-- Adjudicates and authorizes retirement and health insurance claims originating outside the United States that come under special provisions. Evaluates evidence and develops all factual and legal issues. Makes final determinations subject only to the claimant's rights to reconsideration or appeal.

-- Reviews and authorizes disability determinations made by State agencies to establish, continue, deny, or cease insurance for periods of disability. Evaluates medical evidence and vocational factors such as age, education, and work experience. Obtains consultative medical opinions where indicated.

-- Analyzes and evaluates operational problems identified through reports, quality reviews, appraisal programs, vulnerability assessments, delays and backups in operations, and complaints by claimants, beneficiaries, or interest groups to determine causes and develop solutions.

-- Reviews sample cases for one or more programs to improve the quality and consistency of application of instructions, policies, and procedures. Analyzes the nature, source, and pattern of errors and develops reports and plans for improvement.

-- Reconsiders claims that have been requested by or for the claimant or in cases reopened by the agency on its own initiative. As necessary, requests additional development of specific issues and evidence. Prepares final determination that serves as the legal record and basis for supporting or reversing previous decisions.

-- Studies program operations, new legislation, automated systems, management initiatives, and operation of interacting programs and organizations to develop new and modified operating instructions and training material.

Social Insurance Specialist, GS-0105-12

The work requires mastery of the principles, concepts, laws, and systems involved in social insurance program administration and of developments in the field sufficient to interpret and apply new laws and to resolve broad policy issues. The work involves application of expert knowledge of one or more social insurance programs and skill to develop new program policy, comprehensive guidelines, or major new systems; or to extend and refine new approaches and methods to deal with large categories of employees, claimants, recipients, beneficiaries, and employers and the self-employed as a result of new legislation, major court decisions, congressional interest, and management initiatives. Typically, the employee is considered to be a technical authority in a program area by peers, operations managers, and policy makers and is called upon to perform a key role in resolving issues that significantly affect social insurance program administration.

Employees use this knowledge to formulate and analyze options for agency decision memoranda and new guidelines that result from legislation, major decisions by courts, changes in other related programs, or management decisions. Knowledge is used to plan, organize, and lead teams in such activities as the preparation or evaluation and testing of major systemic changes in claims processing. Knowledge is also used to resolve or recommend action on major program issues raised by quality review or operations analysis, General Accounting Office or Inspector General reviews, or congressional committee concern. It is used to develop legislation, regulations, or rulings proposals involving broad program areas and to prepare material for congressional testimony and presentation at national or international meetings by agency officials or for release to the national media.

Illustration:

-- Develops regulations and associated interpretive material to implement new legislation or to rectify major problem areas in program operations in order to insure consistent treatment of Social Security recipients. Researches and analyzes the history and intent of legislation. Develops drafts of proposed regulatory and related material for review and comment by interested parties and projects the potential outcomes of application. Assesses the impact of new or revised guidelines on program operations before making them final and prepares instructions and explanatory material. Serves as an expert interpreter of Social Security law, regulations, and policy and advises others on the intent and application of regulations and legislation.

Training, Other Qualifications, and Advancement

A few jobs in the insurance industry, especially in office and administrative support occupations, require no more than a high school diploma. However, employers prefer to hire workers with a college education for most jobs, including most managerial and professional jobs. When specialized training is required, it usually is obtained on the job or through independent study during work or after-work hours. Many insurance companies expect their employees to take continuing education courses to improve their people skills and their knowledge of the industry. Opportunities for advancement are relatively good in the insurance industry.

Sources of Additional Information

General information on employment opportunities in the insurance industry may be obtained from the human resources departments of major insurance companies or from insurance agencies in local communities. Information about licensing requirements for insurance sales agents and claim adjusters may be obtained from the department of insurance in each State.

For information on the property and casualty segment of the insurance industry, contact:

 

  • Insurance Information Institute, 110 William St., New York, NY 10038. Internet: http://www.iii.org
  • Property Casualty Insurers Association of America, 2600 S. River Rd., Des Plaines, IL 60018. http://www.pciaa.net

For information about the health insurance segment of the insurance industry, contact:

 

  • National Association of Health Underwriters, 2000 North 14th St., Suite 450, Arlington, VA 22201. Internet: http://www.nahu.org

For information about the reinsurance segment of the insurance industry, contact:

 

  • Reinsurance Association of America, 1301 Pennsylvania Ave., NW., Suite 900, Washington DC 20004. Internet: http://www.reinsurance.org

For information about insurance sales careers and training, contact:

 

  • The American Institute for Chartered Property Casualty Underwriters (AICPCU) and Insurance Institute of America, 720 Providence Rd., Suite 100, Malvern, PA 19355. Internet: http://www.aicpcu.org
  • Independent Insurance Agents & Brokers of America, 127 South Peyton St., Alexandria, VA 22314. Internet: http://www.iiaa.org
  • Insurance Vocational Education Student Training (InVEST), 127 South Peyton St., Alexandria, VA 22314. Internet: http://www.investprogram.org
  • National Association of Professional Insurance Agents, 400 North Washington St., Alexandria, VA 22314. Internet: http://www.pianet.org

For information on insurance education and training, contact:

  • The American College, 270 Bryn Mawr Ave., Bryn Mawr, PA 19010. Internet: http://www.theamericancollege.edu
  • LOMA (Life Office Management Association), 2300 Windy Ridge Pkwy., Suite 600, Atlanta, GA 30339-8443. Internet: http://www.loma.org
  • The National Alliance for Insurance Education and Research, P.O. Box 27027, Austin, TX 78755. Internet: http://www.scic.com

Information on obtaining Social Insurance Specialist positions with the Federal Government is available from the Office of Personnel Management through USAJOBS, the Federal Government's official employment information system. This resource for locating and applying for job opportunities can be accessed through the Internet at http://www.usajobs.gov or through an interactive voice response telephone system at (703) 724–1850 or  (703) 724–1850  or TDD (978) 461–8404 and   (978) 461–8404. These numbers are not toll free, and charges may result. For advice on how to find and apply for Federal jobs, download the Insider's Guide to the Federal Hiring Process” online here.

Sources:

  • Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2010-11 Edition; and
  • Office of Personnel Management, Position Classification Standards.

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