Medical Claims Specialist - Workers Compensation

Job description

**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