Claim Associate Jobs in Wisconsin (NOW HIRING)

Job Type: Contract 6 + Months

Shift hours: Monday through Friday 7:45 am and 4:30 pm

Job Summary:

• Under the supervision of the Legal Services Bureau Deputy Director this position is responsible to resolve health care disputes over the reasonableness of fees and necessity of treatment for medical services provided to injured workers; prepare cases for resolution of disputes involving the pharmacy fee schedule; and provide professional and administrative support with handling claim correspondence.
• Resolve health cost disputes involving reasonableness of fees for medical services provided to workers for work related injuries and disputes involving the pharmacy fee schedule.  
• Review and analyze incoming medical cost disputes to ensure they are complete including justifications for medical charges and denial of payment and enter disputes into health cost dispute claim system and Excel.
• Determine via electronic claims system, if a medical dispute is associated with an active worker’s compensation claim. Associate the dispute with a claim file in the claim data base system. Enter dispute information into the WC data base. If a claim does not exist, proceed to initiate the claim.
• Obtain additional information from employers, insurance carriers, employees, attorneys and medical providers to resolve all health cost reasonableness disputes.
• Use the computerized health cost fee database system to locate certified fee information and draft orders for carriers and employers to pay certified amounts in accordance with Wisconsin Statutes, Administrative Rules, and Division guidelines. 
• Document dispute progress and update actions on Excel and claims information system for statistical and reference purposes. 
• Research pharmacy fee schedule disputes and draft appropriate final orders for signature by Deputy Bureau Director or other administrative law judges. The orders must address all significant legal and medical issues raised by the parties, applying appropriate statutory provisions and correct average wholesale price as quoted in the Drug Topics Red Book to the facts of the case. Outline the major factors that were considered in issuing the decision when preparing orders for review and  signature.
• Provide oversight and technical support to other staff in drafting pharmacy fee schedule dispute orders in less complicated cases.
• Prepare cases for resolution of necessity of treatment disputes.  
• Clarify the issues of dispute by reviewing the documentation received. Contact parties of the dispute for additional information by both telephone and/or written correspondence. Determine and document why the claim is in dispute; i.e., cause of injury, pre-existing condition or non-work-related injury.
• Communicate to the parties of litigated claims that the health cost dispute is "on hold" pending resolution of the litigation. 
• Review and analyze the information submitted to ensure disputes meet the pre-established criteria and the case is ready for formal review by an expert panel.
• Compile dispute information on necessity reviews and submit to appropriate private expert for review and opinion.
• Document dispute progress and update actions on Excel and claims information system for statistical and reference purposes.    
• Provide information, instruction and assistance to the public for resolution of complex claim problems including resolution of health cost disputes.
• Answer technical questions presented by the public (injured employees, insurance carriers, employers and their respective attorneys, and health care providers) via telephone and correspondence regarding worker’s compensation law and procedures.
• Conduct informal conferences and interviews with disputing parties to determine the nature of the dispute through review of information submitted. Provide instruction and information concerning worker’s compensation law, rules and procedures.
• Recommend policy and procedure changes to management staff that will improve efficiency and service to the public.

 Knowledges, skills and abilities:

Knowledges:

• Effective oral and written communications
• Knowledge of customer service methods
• Knowledge of investigative techniques
• Knowledge of dispute resolution methods, principles and techniques
• Knowledge of and skill in problem solving and conflict resolution techniques
• Knowledge of medical terminology
• Knowledge of coding for health care service procedures

Skills: 

• Skill in a PC environment
• Skill in working in a team environment
• Effective oral and written communication skills
• Basic mathematic skills to perform payment calculations