Administrative Assistant II

US: Tryfacta•Madison, WI

About The Position

Tryfacta is seeking an Administrative Assistant II for a temporary, six-month contract assignment with a client in Madison, Wisconsin. The role focuses on resolving workers’ compensation health-cost disputes, preparing necessity-of-treatment cases for review, and providing technical information and assistance to the public. The schedule is Monday through Friday, 7:45 a.m. to 4:30 p.m. The position reviews and processes disputes over the reasonableness of fees for medical services related to workplace injuries and pharmacy fee schedules. It analyzes submissions, enters information into claims and dispute systems, obtains supporting information from involved parties, researches applicable fee data and prepares draft orders. It also prepares cases for expert-panel review of treatment-necessity disputes and documents case progress. The role serves as a resource for injured employees, employers, insurers, attorneys and health care providers by answering questions about workers’ compensation law and procedures, conducting informal conferences and interviews, and explaining dispute processes. It may recommend policy and procedural changes to improve service and efficiency.

Requirements

Effective oral and written communication skills.
Knowledge of customer service methods.
Knowledge of investigative techniques.
Knowledge of dispute-resolution methods, principles and techniques.
Knowledge of problem-solving and conflict-resolution techniques.
Knowledge of medical terminology.
Knowledge of coding for health care service procedures.
Skill in a PC environment.
Ability to work in a team environment.
Basic mathematics skills to perform payment calculations.
Ability to read, interpret and apply statutes and administrative rules.
Ability to deal with medical reports, documents and other factual materials.
Ability to work with computer health-service cost databases and imaging systems.
Ability to make difficult and unpopular decisions and work with diverse groups.
Ability to maintain cooperative relationships with co-workers and division staff.

Responsibilities

Review incoming medical-cost disputes for completeness, including supporting justifications for medical charges and payment denials.
Enter dispute information into the health-cost dispute system, Excel, the workers’ compensation database and claims information systems.
Check whether a medical dispute is associated with an active workers’ compensation claim, associate it with the appropriate claim file, and initiate a claim when one does not exist.
Obtain additional information from employers, insurance carriers, employees, attorneys and medical providers to resolve health-cost reasonableness disputes.
Use the computerized health-cost fee database to locate certified fee information and draft payment orders consistent with Wisconsin statutes, administrative rules and division guidelines.
Document dispute progress and actions in Excel and claims information systems for statistical and reference purposes.
Research pharmacy fee-schedule disputes and draft final orders for signature by the Deputy Bureau Director or other administrative law judges, addressing significant legal and medical issues and applying relevant statutes and average wholesale price information from the Drug Topics Red Book.
Outline the major factors considered in decisions when preparing orders for review and signature.
Provide oversight and technical support to staff drafting orders for less complicated pharmacy fee-schedule disputes.
Prepare cases for resolution of treatment-necessity disputes by clarifying disputed issues, reviewing documentation and contacting parties for additional information by telephone or correspondence.
Determine and document why a claim is disputed, including whether the issue involves cause of injury, a pre-existing condition or a non-work-related injury.
Notify parties when a health-cost dispute is on hold pending resolution of litigation.
Review submitted information to determine whether disputes meet established criteria and are ready for expert-panel review; compile case information and submit it to an appropriate private expert for an opinion.
Provide information, instruction and assistance to the public on complex claim problems, including health-cost disputes.
Answer technical questions from injured employees, insurance carriers, employers, attorneys and health care providers by telephone and correspondence regarding workers’ compensation law and procedures.
Conduct informal conferences and interviews with disputing parties to identify the nature of disputes through review of submitted information.
Explain workers’ compensation laws, rules and procedures to the parties.
Recommend policy and procedure changes to management to improve efficiency and service to the public.