Program Assistant with State of Wisconsin

Location: 201 E. Washington Avenue, Madison, WI 53703

Work Arrangement: Onsite
Schedule: Monday through Friday, 7:45 AM to 4:30 PM

Background Check: Wisconsin Department of Justice criminal arrest and conviction records check and completion of the DWD Background Check Form
Security Requirement: Visible photo identification badge, provided by the agency

About The Role

The Worker’s Compensation Specialist will support the Department’s resolution of disputes concerning the reasonableness of medical fees, pharmacy fee schedules, and the necessity of treatment for medical services provided to workers with employment-related injuries. The selected candidate will review incoming healthcare cost disputes, determine whether disputes are connected to active worker’s compensation claims, obtain information from involved parties, calculate appropriate payment amounts, prepare draft orders, and maintain accurate case records. The position also requires frequent communication with injured employees, employers, insurance carriers, attorneys, healthcare providers, and other stakeholders regarding Wisconsin worker’s compensation laws, procedures, and dispute-resolution processes.

Responsibilities

Medical Cost and Pharmacy Fee Disputes

• Review and analyze medical cost disputes for completeness, including justifications for medical charges and payment denials.
• Enter dispute information into the health cost dispute claim system, worker’s compensation databases, and Excel tracking files.
• Determine whether each dispute is associated with an active worker’s compensation claim.
• Associate disputes with existing claim files or initiate claims when no claim exists.
• Obtain additional information from employers, insurance carriers, employees, attorneys, and medical providers.
• Use computerized healthcare fee databases to identify certified fee information.
• Calculate payment amounts and prepare draft orders requiring carriers or employers to pay certified amounts.
• Apply applicable Wisconsin statutes, administrative rules, and Division guidelines.
• Research pharmacy fee schedule disputes and prepare final orders for review and signature.
• Apply the correct average wholesale drug prices using the Drug Topics Red Book.
• Address significant legal and medical issues raised by the parties.
• Document the primary factors considered when preparing decisions and orders.
• Provide technical support to other staff preparing less-complex pharmacy fee schedule dispute orders.

Treatment-Necessity Disputes

• Review submitted documentation to identify and clarify disputed issues.
• Contact involved parties by telephone or written correspondence to obtain additional information.
• Determine whether disputes involve the cause of injury, pre-existing conditions, or non-work-related injuries.
• Notify parties when a health cost dispute is placed on hold pending the resolution of related litigation.
• Evaluate whether submitted disputes meet established criteria for formal expert review.
• Compile case materials and submit necessity-of-treatment disputes to appropriate private experts for review and opinion.
• Track case progress and update actions in Excel and the claims information system.

Public and Stakeholder Support

• Respond to technical questions from injured workers, employers, insurance carriers, attorneys, and healthcare providers.
• Explain worker’s compensation laws, administrative rules, procedures, and health cost dispute requirements.
• Conduct informal conferences and interviews with disputing parties.
• Review submitted information to determine the nature of disputes.
• Assist parties with understanding applicable claim and dispute-resolution procedures.
• Recommend policy or process improvements that could increase operational efficiency and improve public service.

Required Knowledge and Skills

• Effective verbal and written communication skills.
• Strong customer-service skills.
• Knowledge of investigative techniques.
• Understanding of dispute-resolution methods, principles, and practices.
• Problem-solving and conflict-resolution skills.
• Knowledge of medical terminology.
• Familiarity with healthcare service procedure coding.
• Proficiency in a personal-computer environment, including Microsoft Excel.
• Ability to work effectively in a team environment.
• Basic mathematical skills required to perform healthcare payment calculations.
• Ability to review, interpret, and apply statutes and administrative rules.
• Ability to analyze medical reports, claim documents, correspondence, and other factual materials.
• Ability to work with computerized healthcare cost databases, claim-management systems, and document-imaging systems.
• Ability to make difficult or potentially unpopular decisions based on applicable laws, rules, and evidence.
• Ability to work professionally with diverse groups and maintain cooperative relationships with coworkers and Division personnel.

Preferred Candidate Background

Strong candidates should have prior experience in one or more of the following areas:

• Worker’s compensation claims administration.
• Healthcare billing, medical claims, or insurance claims processing.
• Medical coding or healthcare reimbursement.
• Legal, regulatory, or administrative case review.
• Healthcare fee schedules or pharmacy pricing.
• Claims investigation and dispute resolution.
• Preparing formal correspondence, findings, recommendations, or administrative orders.
• Communicating with attorneys, insurance carriers, employers, medical providers, and members of the public.

Ideal Candidate

The ideal candidate will have strong analytical, administrative, and communication skills, along with experience reviewing medical claims, healthcare billing information, insurance disputes, or worker’s compensation documentation. The individual should be comfortable interpreting statutes and administrative rules, performing payment calculations, reviewing medical and legal records, preparing detailed written decisions, maintaining accurate case documentation, and communicating with parties who may disagree with the agency’s findings. Because this role involves sensitive claims, healthcare information, and potentially disputed decisions, the candidate must demonstrate sound judgment, attention to detail, impartiality, confidentiality, and the ability to manage difficult stakeholder interactions professionally.