State of Washington Classified Job Specification
MEDICAL TREATMENT ADJUDICATOR 1
Review and authorize or deny payment of bills from physicians, hospitals, therapists, pharmacies, vocational providers or other medical agents, under the State Industrial Accident Insurance Program; adjudicate exception bills in accordance with the Industrial Insurance Act, the current Medical Aid Rules and Fee Schedules and utilization review and cost containment policies adopted by the department. Explains benefits, rights, and responsibilities to injured workers, providers, and other customers through written and verbal communications. Evaluate authorization and eligibility information to determine if services billed are appropriate and authorized. Verifies, updates or adjusts client eligibility and authorization information in the Labor and Industries Industrial Insurance System.
Reviews and authorizes or denies payment of bills from physicians, hospitals, therapists, pharmacies and other providers of services taking into consideration the available medical data, the nature of the injury and the legal status of the claim; determines if items billed were authorized by the Department and in compliance with the Industrial Insurance Act and the current Medical Aid Rules; adjusts and computes the appropriate payment for items billed in accordance with the Maximum Fee Schedule; determines an equitable fee for procedures not listed in the Maximum Fee Schedule; responds to written and telephone inquiries from medical vendors, claimants, attorneys and employers; writes correspondence requesting additional information and explaining adjustments or disallowance of bills;
Performs other related work as required.
Knowledge and Abilities
Knowledge of: the Medical Aid Rules and the Industrial Insurance Act as related to medical treatment; medical and therapeutic terms; anatomy; drugs.
Ability to: review bills for payment and make proper determination regarding allowance, rejection or adjustment of the bills; interpret available medical information, the intent of court orders and Departmental orders; write clear, concise, accurate and informative correspondence to medical vendors, claimants, attorneys and employers using tact and diplomacy; establish and maintain effective working relationships with physicians, hospitals, therapists, pharmacies and other practitioners in the medical field.
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.
Graduation from high school and two years of experience involving work with industrial insurance claims or in processing financial records, such as accounts receivable, payrolls, bill payment, claims adjusting, military medical corpsman, medical social worker or in closely allied field.
Additional college or business school education may be substituted, year for year, for experience.
Additional qualifying experience may be substituted, year for year, for education.
Class Specification History
Re-titled from Disability Claims Adjudicator I and specification amended. 6 26 64
Revised October 1, 1968 Revises minimum qualifications
Revised August 9, 1971 Revises minimum qualifications
Revised October 12, 1979 Revises definition and general revision
Revised March 11, 1983 Revises Class Code. (Formerly 4782)
Revised salary and definition: June 9, 2000
New class code: (formerly 47830) effective July 1, 2007