Have you worked with workers’ compensation medical only claims? Do you have experience interpreting industrial insurance statutes (Title 51), Medical Aid rules, and relevant regulations?
Would you like to work with a group of dynamic, dedicated, passionate people who are committed to transforming healthcare in the state of Washington? If this sounds like something you would like to be part of, we want to talk to you about a career with Washington Hospital Services, a subsidiary of the Washington State Hospital Association.
WSHA has been in existence for over 80 years and continues to grow and evolve as the needs of Washington Residents and our member hospitals change. We are located in beautiful downtown Seattle, surrounded by wonderful views of Puget Sound and the Olympic mountains, with easy access to transit and underground parking, and we are currently recruiting for a Workers’ Compensation – Medical Only Adjudicator to join our Workers Compensation team.
The Workers’ Compensation -Medical Only Adjudicator position is a full-time position and is responsible for interpreting and applying relevant state laws to workers compensation – medical only claims, evaluating medical reports, working with external specialty providers, management of the claims through to resolution, and assisting clients in the return to work accommodation process. This position will report to the Director of Safety and Client Services in our wholly owned for-profit subsidiary, Washington Hospital Services (WHS), and will be expected to fully manage the entire life cycle of a workers’ compensation – medical only claim.
Specific duties of this position include, but are not limited to:
- Adjudicate workers’ compensation claims to interpret facts and apply laws to determine claim validity and manage ongoing appropriate and timely claim management activities necessary to bring resolution at the earliest possible time in a cost-effective manner.
- Initiate and complete the 2-point contact within 48 hours of receipt of a new claim.
- Establish initial case reserves for the life of each claim at the time of initial claim review and review case reserves every 60 days making necessary adjustments based upon anticipated medical, PPD, vocational, legal or other costs.
- Conduct a comprehensive file review, take appropriate actions, and complete a Claim Status Summary Report and written Plan of Action (POA) every 60 days.
- Maintain a current claims diary, defined per performance standards.
- Complete timely review and acknowledge receipt of claim documents, record document note entry, take appropriate action and record actions taken in response to documents received and reviewed.
- Review claim file documents to determine if disability benefits may be owed and timely transfer the claim file to a Time Loss Adjuster.
- Review claim file documents authorization or denial requests for medical treatment, surgery, diagnostic studies, transfers of medical care; refer for vocational, investigative or legal services and/or submit claim for closure.
- Review determinative orders received from the Department of Labor & Industries for the purposes of ensuring they are accurate and represent our interpretation of the facts of the claim and file timely protests or appeals as warranted.
- Evaluate medical reports to determine appropriate permanent partial disability awards.
- Communicate both verbally, and in writing with Department of Labor & Industries staff, designated hospital contacts, physicians, injured workers, claimant and employer attorneys, and other stakeholders.
- Develop and maintain a professional and positive working relationship with all stakeholders.
- Secure, manage and direct the services of outside specialty providers (e.g., independent medical providers, vocational counselors, nurse case managers, defense counselors, and investigators).
- Identify and update injured worker’s physical restrictions and assist clients in the return to work accommodation process and/or transfer the claim to a Time Loss Adjuster.
- Investigate and pursue Third Party subrogation claims.
- Approve medical payments on claim files on a weekly basis.
- Prepare claims for closure with the Department of Labor & Industries or close claims in house following appropriate procedures.
- Complete claim status reviews with clients on an as needed basis.
- Work with designated hospital contacts to answer questions, educate and update them on the status of assigned claims on an ongoing basis.
- Attend and represent Washington Hospitals Services Workers’ Compensation Program at self-insured meetings, seminars and other meetings as designated.
- Perform other duties as assigned.
Desired qualifications, skills, and abilities
- Bachelor’s degree in business, marketing, or related field or equivalent combination of education and experience.
- A minimum of one (1) years’ experience working with Workers Compensation – Medical only claims.
- Demonstrated knowledge of relevant state laws (RCW 51 and WAC 296)
- Exceptional customer/member service skills and superior interpersonal and communication skills required.
- Demonstrated ability to exercise sound judgment and maintain confidentiality.
- Strong analytical and organizational skills, detail orientation required.
- Must be a self-starter and innovator.
- Ability to work successfully independently or in a collaborative, team environment.
- Ability to successfully manage multiple priorities simultaneously.
- Access to a vehicle and ability to periodically travel within Washington State to member hospitals.
- Proficient with MS office, Outlook, Word, Excel required. Familiarity with workers compensation databases, experience with paperless systems and knowledge of computerized claims processing required, knowledge of ERIC system a plus.
How to apply
If you have the skills and abilities listed above, feel that you would be a good fit for this position and would like to be part of this exceptional organization, please apply through our career center at the link below:
No calls please. WSHA is an Equal Opportunity Employer.