Brief Job Description:

Responsible for medical case management/ medical bill review in the Workers’ Compensation Service. Under the supervision of the Workers’ Compensation Agent, coordinates bill paying activity using utilization review guidelines. Works with workers’ compensation case managers and claims manager(s) to perform medical case management, provide approval for bill payment, provide medical explanations, and utilize the vendor payment software. Also confers with attorneys on litigated cases involving medical issues. Properly utilize vendors for utilization review, peer reviews, and medical case management as needed. Provide statistics regarding the cost of medical treatment for Workers’ Compensation claimants. Also, based upon statistics, develop risk management techniques to reduce medical costs associated with Workers’ Compensation.

• Manages medical care for City of Boston injured employees, while keeping close watch on medical costs.
• Oversees payments/inputs on all medical billing, including medical bills, pharmacy, reimbursements, etc.
• Negotiates all surgical procedures.
• Monitors all changes in state regulations regarding code and policy changes to ensure compliance.
• Works closely with claims department, attorneys and other Workers’ Compensation Service staff members.
• Communicates with employee’s treating providers, i.e. doctors, rehabilitation therapists, chiropractors, dentists, etc. as appropriate.
• Records/ Documents all employee’s medical treatment in Riskmaster claims system.
• Oversees Utilization Review companies hired to perform all UR.
• Processes mandatory quarterly reporting to Medicare on all eligible beneficiaries.
• Performs related duties as assigned.

• At least (4) four years’ experience in a professional or technical field. An undergraduate degree may be substituted for two years of the required experience. A Masters may be substituted for (3) three years.
• ( LPN) Licensed practical nurse required, (RN) registered nurse preferred.
• Experience in Workers’ Compensation is highly preferred.
• Knowledge of Utilization Review Guidelines preferred.
• Ability to review medical bill processing in Xybion vendor payment system.
• Experience in Insurance Rehabilitation, Medical Case Management is highly preferred.
• Experience with Google Suite, Microsoft Office and Adobe.
• Willingness to learn various claims management software such as Riskmaster and Xybion’s Emidence vendor payment software.
• Familiarity with M.G.L. c. 152 and 452 C.M.R. preferred.
• Ability to exercise good judgement and focus on detail as required by the job.

Boston Residency Required.

Terms:

Union/SalaryPlan/Grade:SENA-MM1-9

Hours per week: 35