State of Washington Classified Job Specification
MEDICAL TREATMENT ADJUDICATOR 2
Authorize medical treatment, rehabilitation treatment and services, and prosthetics under State Industrial Accident Insurance Program; audits work performance of Medical Treatment Adjudicators 1; or serves as a Medical Treatment Adjudicator 1 Leadworker.
Reviews and evaluates claims from a medical treatment standpoint to determine proper course of action in accordance with the Industrial Insurance Laws and the Medical Aid Rules; considers and interprets the intent of court orders and Departmental orders; evaluates and authorizes or denies requests for medical treatment, surgery, diagnostic studies, etc., basing the decision on the medical data in the file, the nature of the injury, and the legal status of the claim; evaluates and approves or denies requests from claimants or their attorneys for transfer of physician, reimbursement of travel expense, etc.; tactfully responds to protests from claimants, attorneys, physicians, hospitals and other health care providers keeping in mind the maintenance of good public relations; monitors claims to ensure that the health care provided is up to the standard of modern medicine;
Composes and dictates medical examinations and clear, concise, accurate and informative letters to physicians, hospitals, claimants, attorneys and other providers of service;
Advises and assists lower level adjudicators in the adjustment and payment of medical bills in complex or complicated claims;
Reviews and evaluates claims to determine appropriateness of referrals to the Rehabilitation Center and Vocational Counselors; monitors claimant's response or lack of response to Rehabilitation services; periodically reviews amputee claims regarding treatment, prosthetic and Rehabilitation needs; approves or disallows bills for prosthetic services;
Performs other related work as required.
Knowledge and Abilities
Knowledge of: Workmen's Compensation and Medical Aid Acts as they relate to medical treatment, medical terms, anatomy, drugs, prosthetic devices.
Ability to: review requests for authorization for medical or therapeutic treatment and to make proper determination regarding State responsibility for such treatment; write clear, concise, accurate and informative correspondence to medical practitioner using tact and diplomacy, especially when denying requested treatment for claimants; establish and maintain effective working relationships with physicians, therapists, chiropodists, osteopaths, chiropractors, hospital officials and other practitioners in the medical field; analyze medical and accident facts and circumstances and draw valid conclusions.
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.
A Bachelor's degree.
Completion of two years' college or recognized business school and two years of experience in claims adjusting, insurance adjusting, claims investigation, paramedical occupation or increasingly responsible administrative experience in business or governmental work.
Additional qualifying experience may be substituted, year for year, for education.
Additional medically related education may be substituted, year for year, for experience.
For Promotion Only: One year of experience as a Medical Treatment Adjudicator.
Class Specification History
June 26, 1964 Re-titled from Disability Claims Adjudicator II, 4784, and specification amended
Revised October 1, 1968 Revises minimum qualifications
Revised October 12, 1979 Revises definition, minimum qualifications and general revision
Revised March 11, 1983 Revises Class Code (Formerly 4783)
Revised definition: June 9, 1989
Revised definition: June 9, 2000
New class code: (formerly 47840) effective July 1, 2007