Medical Claims Specialist, Remote
Gainwell Technologies
Medical Claims Specialist – Workers' Compensation
Berkshire Hathaway Homestate Companies - Workers Compensation Division
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- 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.
Requirements
- Minimum of High School Diploma or equivalent certificate required.
- Administrative experience in the areas of law, medicine, insurance/workers compensation, telephonic communication, or negotiation is useful but not necessary.
- 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.
- Able to effectively use Microsoft Office Suite applications. Able to quickly master proprietary and vended software applications.
