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State of Washington Classified Job Specification

MEDICAL TREATMENT ADJUDICATOR 3

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MEDICAL TREATMENT ADJUDICATOR 3
171G
Category: Financial Services

Definition

Supervise and direct the authorization of medical treatment, physical and occupational therapy, and rehabilitation services and bill adjudication; train new Medical Treatment Adjudicators 1 and 2 and upgrade training for all medical treatment and bill adjudication staff.

Typical Work

Plans, assigns and supervises Medical Treatment Adjudicators 2 and clerical staff; assists in coordinating and implementing policies and procedures relative to medical management of Industrial Insurance claims; responds to inquiries from health care providers regarding the Industrial Insurance Act, the Medical Aid Rules and Fees, and the Department's policies; 

Supervises review of claims to determine appropriateness of referrals to the Rehabilitation Center and periodic check of rehabilitation cases at intervals for statistical determination of effectiveness of Rehabilitation treatment; monitors cases in which supervisor of industrial insurance has granted approval for retraining; assists in the development and implementation of group and individual training programs for the medical treatment adjudication staff; trains all new Medical Treatment Adjudicators 1 and 2; upgrades training for all medical treatment adjudication staff as new procedures and policies are developed and established; 

Maintains and revises the Medical Aid Fee Schedule; coordinates with other agencies regarding fees and procedure numbers; plans and coordinates publication of the Medical Aid Fee Schedule with the Code Revisor and the print shop; monitors the medical aid payment and information system to isolate and identify problem areas; coordinates and implements solutions to these problems with data processing and the adjudication staff; 

Advises and assists lower-level adjudicators in the authorization of complex treatment problems and unusual treatment procedures and in the adjustment and payment of medical bills; instructs lower-level adjudicators in the use of tact and diplomacy in dealing with the medical practitioners and in writing clear, concise, accurate and informative correspondence to medical practitioners; 

Participates in and/or conducts seminars on the Industrial Insurance Program for various groups including health care providers and their staff; 

Performs other related work as required.

Knowledge and Abilities

Knowledge of:  Workers' Compensation and Medical Aid Acts as they relate to medical treatment; medical terms; anatomy, drugs, prosthetic devices; principles of effective supervision. 

Ability to:  analyze medical accident facts and circumstances and draw valid conclusions; interpret the intent of court and departmental orders; write clear, concise, accurate and informative correspondence; establish and maintain effective working relationships with health care providers, injured worker, employers and the public; speak before various groups regarding the Industrial Insurance and Medical Aid Laws.

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

Two years of separate or combined experience as a Medical Treatment Adjudicator 1 or 2  

OR 

A Bachelor’s degree and two years of experience as a medical or claims adjudicator, insurance investigator, registered nurse, military corpsman, medical social worker or closely allied field. 

Additional qualifying experience may be substituted, year for year, for education.

Class Specification History

Revised from Medical Treatment Adjudicator I, 4793, and specification amended June 26, 1964
Revised minimum qualifications October 1, 1968
Revised definition, minimum qualifications and general revision October 12, 1979
Revised class code (formerly 4784) March 11, 1983
Revised minimum qualifications May 13, 1988
Revised definition June 9, 1989
Revised definition and minimum qualifications: June 9, 2000
New class code: (formerly 47850) effective July 1, 2007

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