Claims Resolution Specialist / Claims Resolution Representative

Job Description

Job Description

Duration : 6+ Months

Job Description:

Work Arrangement

Hybrid: In-person work is required after the initial training period, with approximately 2–3 days per week in the office .

Position Summary

Under the supervision of the Legal Services Bureau Deputy Director , the Worker’s Compensation Specialist – HCD is responsible for resolving health care disputes involving the reasonableness of fees and necessity of treatment for medical services provided to injured workers.

The position also prepares cases for resolution of disputes involving the pharmacy fee schedule and provides professional and administrative support in handling workers’ compensation claim correspondence and related matters.

Key Responsibilities

Health Cost & Pharmacy Fee Dispute Resolution – 60%

• Review and analyze incoming medical cost disputes to ensure completeness, including supporting documentation, medical charges, and payment-denial justifications.
• Enter disputes into the health cost dispute claim system and Excel tracking systems.
• Determine whether medical disputes are associated with active workers’ compensation claims using electronic claims systems.
• Associate disputes with appropriate claim files and enter relevant information into the workers’ compensation database.
• Initiate a claim when no existing claim is identified.
• Obtain additional information from employers, insurance carriers, employees, attorneys, and medical providers to resolve health cost disputes.
• Use computerized health cost fee databases to locate certified fee information.
• Draft orders directing carriers and employers to pay certified amounts in accordance with Wisconsin Statutes, Administrative Rules, and Division guidelines .
• Maintain accurate documentation of dispute progress and update Excel and claims information systems for statistical and reference purposes.
• Research pharmacy fee schedule disputes and prepare appropriate final orders for review and signature by the Deputy Bureau Director or Administrative Law Judges.
• Ensure orders address significant legal and medical issues raised by the parties and apply appropriate statutory provisions and applicable average wholesale pricing information from the Drug Topics Red Book .
• Prepare outlines of the major factors considered in decisions for review and signature.
• Provide technical assistance and oversight to staff preparing pharmacy fee schedule dispute orders involving less complex cases.

Necessity of Treatment Disputes – 30%

• Review submitted documentation to clarify the issues involved in treatment-necessity disputes.
• Contact disputing parties by telephone and written correspondence to obtain additional information.
• Determine and document the basis for the dispute, including:
• • Cause of injury
  • Pre-existing conditions
  • Non-work-related injuries
• Notify parties involved in litigated claims when health cost disputes are placed on hold pending resolution of litigation.
• Review submitted information to determine whether disputes meet established criteria and are ready for formal expert-panel review.
• Compile relevant dispute information and submit cases to appropriate private experts for review and opinion.
• Maintain accurate records of dispute progress and update Excel and claims information systems.

Public Information, Assistance & Process Improvement – 10%

• Respond to technical questions from injured employees, insurance carriers, employers, attorneys, and health care providers regarding workers’ compensation laws and procedures.
• Provide information and guidance through telephone and written correspondence.
• Conduct informal conferences and interviews with disputing parties to identify and clarify the nature of disputes.
• Review submitted information and explain applicable workers’ compensation laws, rules, and procedures.
• Identify opportunities for improving processes and recommend policy or procedure changes to management.
• Support improvements in efficiency, consistency, and service to the public.

Required Knowledge, Skills & Abilities

• Strong oral and written communication skills.
• Knowledge of customer service methods and practices.
• Knowledge of investigative techniques.
• Knowledge of dispute resolution methods, principles, and techniques.
• Strong problem-solving and conflict-resolution skills.
• Knowledge of medical terminology.
• Knowledge of health care service procedure coding.
• Ability to analyze medical, administrative, and legal documentation.
• Ability to communicate effectively with employees, employers, attorneys, insurance carriers, and health care providers.
• Ability to maintain accurate records and manage multiple cases simultaneously.
• Ability to interpret and apply applicable rules, procedures, and statutory requirements.
• Strong attention to detail and documentation skills.
• Proficiency with computerized claims databases and Microsoft Excel or similar tracking systems.

Primary Areas of Expertise

• Workers’ compensation claims
• Health care cost disputes
• Medical fee schedules
• Pharmacy fee schedules
• Medical necessity reviews
• Claims investigation
• Dispute resolution
• Legal and regulatory research
• Medical terminology and procedure coding
• Case documentation and database management
• Customer service and stakeholder communication
• Administrative order preparation

22nd Century Technologies, Inc. (TSCTI) is one of the fastest-growing IT Services Integrators and Workforce Solutions providers in the United States. Founded in 1997, TSCTI is a Certified National Minority Business Enterprise (MBE) with a workforce of 6,000+ professionals, including 600+ Cybersecurity Subject Matter Experts (SMEs), delivering mission-critical solutions across all 50 U.S. states, Canada, and Mexico.

Headquartered in Princeton, NJ, and McLean, VA, with 14 regional offices nationwide, TSCTI provides comprehensive solutions in Digital Transformation, Artificial Intelligence (AI), Cybersecurity, Cloud Computing, IT Infrastructure, Enterprise Modernization, DevSecOps, Managed Services, Workforce Solutions, and Healthcare Staffing. We are a trusted partner to Federal, State, Local, Education (SLED), Healthcare, and Commercial organizations, delivering innovative technology and talent solutions that enable our clients to achieve their strategic objectives.

As one of the nation's leading Healthcare Workforce Solutions providers, TSCTI supports federal healthcare systems, Veterans Affairs (VA) Medical Centers, state and local healthcare agencies, hospitals, clinics, laboratories, long-term care facilities, and commercial healthcare organizations. We recruit and place highly qualified healthcare professionals across a wide range of specialties, including physicians, advanced practice providers, registered nurses, allied health professionals, behavioral health specialists, laboratory personnel, pharmacy professionals, and healthcare administrative staff. Our healthcare solutions ensure continuity of care while maintaining the highest standards of clinical excellence and regulatory compliance.

With a strong commitment to quality and compliance, TSCTI operates through CMMI Level 3 (Development & Services) and ISO 9001, ISO 20000, and ISO 27001 certified processes, ensuring consistent service excellence, operational maturity, and information security. Today, we proudly support 14 of the 15 Federal Executive Departments, 37 Federal agencies, 50 State governments, 115+ Local agencies, 37 School Districts, numerous healthcare organizations, and 80+ Fortune 500 and commercial clients.

TSCTI has earned numerous industry recognitions, including being named among Forbes America's Best Large Employers, Forbes Best Employers for Veterans, Forbes Best Employers for Tech Workers, Newsweek's America's Greatest Workplaces for Diversity, and a 13-time Inc. 5000 honoree. The company has also been recognized by the Washington Business Journal as one of the Best Places to Work and continues to expand its capabilities through strategic innovation, acquisitions, and investments in emerging technologies.

At TSCTI, our people are our greatest strength. We are committed to fostering an inclusive, collaborative, and growth-oriented workplace where innovation thrives and careers flourish. Whether delivering cutting-edge technology solutions or connecting exceptional talent with meaningful careers, we consistently exceed our clients' expectations while empowering our employees to succeed.

Equal Opportunity Employer

22nd Century Technologies, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Company Description

22nd Century Technologies, Inc. (TSCTI) is one of the fastest-growing IT Services Integrators and Workforce Solutions providers in the United States. Founded in 1997, TSCTI is a Certified National Minority Business Enterprise (MBE) with a workforce of 6,000+ professionals, including 600+ Cybersecurity Subject Matter Experts (SMEs), delivering mission-critical solutions across all 50 U.S. states, Canada, and Mexico.\r\n\r\nHeadquartered in Princeton, NJ, and McLean, VA, with 14 regional offices nationwide, TSCTI provides comprehensive solutions in Digital Transformation, Artificial Intelligence (AI), Cybersecurity, Cloud Computing, IT Infrastructure, Enterprise Modernization, DevSecOps, Managed Services, Workforce Solutions, and Healthcare Staffing. We are a trusted partner to Federal, State, Local, Education (SLED), Healthcare, and Commercial organizations, delivering innovative technology and talent solutions that enable our clients to achieve their strategic objectives.\r\n\r\nAs one of the nation's leading Healthcare Workforce Solutions providers, TSCTI supports federal healthcare systems, Veterans Affairs (VA) Medical Centers, state and local healthcare agencies, hospitals, clinics, laboratories, long-term care facilities, and commercial healthcare organizations. We recruit and place highly qualified healthcare professionals across a wide range of specialties, including physicians, advanced practice providers, registered nurses, allied health professionals, behavioral health specialists, laboratory personnel, pharmacy professionals, and healthcare administrative staff. Our healthcare solutions ensure continuity of care while maintaining the highest standards of clinical excellence and regulatory compliance.\r\n\r\nWith a strong commitment to quality and compliance, TSCTI operates through CMMI Level 3 (Development & Services) and ISO 9001, ISO 20000, and ISO 27001 certified processes, ensuring consistent service excellence, operational maturity, and information security. Today, we proudly support 14 of the 15 Federal Executive Departments, 37 Federal agencies, 50 State governments, 115+ Local agencies, 37 School Districts, numerous healthcare organizations, and 80+ Fortune 500 and commercial clients.\r\n\r\nTSCTI has earned numerous industry recognitions, including being named among Forbes America's Best Large Employers, Forbes Best Employers for Veterans, Forbes Best Employers for Tech Workers, Newsweek's America's Greatest Workplaces for Diversity, and a 13-time Inc. 5000 honoree. The company has also been recognized by the Washington Business Journal as one of the Best Places to Work and continues to expand its capabilities through strategic innovation, acquisitions, and investments in emerging technologies.\r\n\r\nAt TSCTI, our people are our greatest strength. We are committed to fostering an inclusive, collaborative, and growth-oriented workplace where innovation thrives and careers flourish. Whether delivering cutting-edge technology solutions or connecting exceptional talent with meaningful careers, we consistently exceed our clients' expectations while empowering our employees to succeed.\r\n\r\nEqual Opportunity Employer\r\n\r\n22nd Century Technologies, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.