Medical Claims Specialist - Workers Compensation

Berkshire Hathaway Homestate Companies - Workers Compensation Division; San Diego (CA); On-site; USD 52,000 - 58,000; Full time

Benefits offered by this job

Work From Home Program (up to 2 days/w

Free On-Site Fitness Facility

Free On-Site Garage Parking

Job summary

Berkshire Hathaway Homestate Companies in San Diego, CA seeks a Medical Claims Specialist to manage a caseload of workers’ compensation medical-only claims after successful training.

Role involves learning medical and legal aspects, using computer systems for claims, and ensuring compliance with regulations while building strong client relationships.

Qualifications

• Education: High School Diploma or equivalent required.
• Experience: Administrative experience in law, medicine, workers’ compensation, telephonic communication, or negotiation is useful but not necessary.
• Reasoning ability: Apply common sense to carry out written, oral, or diagram instructions.
• Computer skills: Proficient in Microsoft Office Suite; able to quickly learn proprietary and vendor software.

Responsibilities

• Successfully completes the Medical Claims Training Program.
• In classroom training, is attentive, takes notes, asks questions, participates in exercises, and masters the material.
• In the Medical Claims Unit, asks questions, improves under supervision, and demonstrates mastery of adjusting concepts.
• Learns medical topics (anatomy, physiology, pharmacology) and legal subjects relevant to claims.
• Learns to effectively use computer systems for claims management; develops investigative and communication skills.
• Establishes and maintains sound relationships with client contacts for dedicated Claims Medical Specialist; determines coverage for new claims.
• Investigates new claims to determine compensability, severity, and gathers relevant information.
• Calculates reserves and ensures adjustments; ensures benefits comply with laws and filings.
• Manages each claim to a successful resolution; follows company procedures and guidelines.
• Fosters collaboration with Call Center, Medical Management, Client Services, and indemnity staff.

Skills

Attention to detail

Communication

Investigative skills

Decision making

Documentation

Microsoft Office

Computer systems

Education

High School Diploma

Tools

Proprietary software

Vended software

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.

• 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.

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&DD Insurance
• Long Term Disability Insurance
• Paid Community Volunteer Day
• Employee Assistance Program
• Tuition Reimbursement Program
• Employee Referral Program
• Diversity, Equity and Inclusion Program

In accordance with the California Equal Pay Act, the starting hourly wage for this job is $26.4424. This hourly wage is what the employer reasonably expects to pay for the position based on potential employee qualifications, operational needs and other considerations consistent with applicable law. The pay scale applies only to this position and only if it is filled in California. The pay scale may be different for other positions or in other locations.

About Us

With more than 50 years in business, BHHC has grown from a regional organization to a national insurance group, offering insurance products from coast to coast. Relationships are the cornerstone of our culture, and we believe in doing the right thing. That means we invest in our business in every way possible to deliver on our mission and demonstrate that people are what powers our success. Our commitment to financial strength and integrity means our customers can rest assured that we will be there when it counts. At BHHC we embrace diversity and foster an environment where our people can be their authentic selves. Our differences make us stronger and better together, which foster a harmonious workplace—something we truly value. We’ve created an approachable and collaborative atmosphere. Here you’ll find a welcoming workplace where everyone can feel valued, supported, and inspired to do great work. Together, we raise the bar by being curious, remaining customer-focused, and operating with integrity.