Posted 4 months ago

Medical Claims Specialist - Workers Compensation

San DiegoHybridFull-time

AI Summary

Manages a caseload of workers' compensation medical-only claims from inception to resolution, including coverage determination, investigation, reserve calculation, and ensuring legal compliance.

About this role

WHAT WE'RE LOOKING FOR

Berkshire Hathaway Homestate Companies has an opening in our San Diego, CA office for a Medical Claims Specialist. After successful completion of the Medical Claims Training Program, this individual will manage a caseload of workers’ compensation medical-only claims from inception to resolution.

ESSENTIAL RESPONSIBILITIES

Successfully completes the Medical Claims Training Program.

In classroom training, is attentive, takes notes, asks appropriate questions, participates successfully in exercises, and demonstrates mastery of the subject material.

In the Medical Claims Unit, asks appropriate questions, exhibits continuous improvement under the guidance of the supervisor, and demonstrates mastery of fundamental adjusting knowledge, skills, and strategy.

Learns medical subjects including anatomy, physiology, terminology, pharmacology, causation, nature of the injury, and diagnostic and treatment methodology.

Learns legal subjects including relevant statutes and regulations.

Learns to effectively and efficiently use the computer systems employed in the management of claims.

Learns skills such as investigative and persuasive communication, decision-making, and documentation.

For clients who are provided with a dedicated Claims Medical Specialist, establishes and maintains a sound working and communication relationship with the client’s contact personnel.

Determines coverage for new claims.

Conducts and directs the investigation of new claims to determine compensability and severity and to gather all other relevant information.

Calculates appropriate reserves and ensures that reserves are adjusted as needed.

Ensures that benefits are provided in accordance with the law and that the claim as a whole is managed in accordance with all legal requirements including the issuance of appropriate notices and filings.

Manages each claim to an appropriate and successful resolution.

Ensures that work is performed in accordance with Company procedures, standards, training, and supervisory direction.

Fosters a positive and close working relationship with other Company staff, including the Call Center, Medical Management teams, Client Services, and indemnity Adjusting staff.

REQUIRED QUALIFICATIONS

EDUCATION: Minimum of High School Diploma or equivalent certificate required.

EXPERIENCE: Administrative experience in the areas of law, medicine, insurance/workers compensation, telephonic communication, or negotiation is useful but not necessary.

REASONING ABILITY: Able to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Able to deal with problems involving several concrete variables in standardized situations.

COMPUTER SKILLS: Able to effectively use Microsoft Office Suite applications. Able to quickly master proprietary and vended software applications.

WHAT WE OFFER

Manageable Caseloads

Work-Life Balance

Work From Home Program (up to 2 days per week)

Free On-Site Fitness Facility

Free On-Site Garage Parking

BENEFITS

Paid Time Off

Paid Holidays

Retirements Savings Match

Group Health Insurance (Medical, Dental, and Vision)

Life and AD&D Insurance

Long Term Disability Insurance

Paid Community Volunteer Day

Employee Assistance Program

Tuition Reimbursement Program

Employee Referral Program

Diversity, Equity and Inclusion Program

Skills

AnatomyDocumentationInvestigative CommunicationMedical TerminologyMicrosoft OfficeNegotiationPersuasive CommunicationPharmacologyPhysiologyProprietary Claims SoftwareStatutes And RegulationsTelephonic CommunicationVended Software ApplicationsWorkers' Compensation Law