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Medical Claim Specialist

1 month ago

Honolulu, United States HEMIC Full time
Job DescriptionJob Description

Join us at HEMIC

Voted one of Hawai`i Business’ Best Places to Work for 6 Years in a Row

As a HEMIC employee, you will get:

  • People Who Care

Voted one of Hawai`i Business’ Best Places to Work, and Pacific Business News’ Best Workplaces, our business is founded on caring for Hawai`i workers, Hawai`i businesses, and each other.

  • Professional Growth

We’re passionate about your development. Whether it’s achieving a formal certification or attending a workshop to improve your communication skills, we will support and encourage you to grow.

  • Benefits & Perks

We offer competitive salary and best-in-class benefits, including a 401k match, flex-time, generous PTO, 15 paid holidays, and so much more

  • Opportunity to Give Back

Giving back to our community is our kuleana and we offer numerous opportunities for our employees to take part - whether it be volunteering for a fundraiser, attending a charity walk, or getting a match for your charitable contributions.

Why our Medical Claim Specialist is Important:

A company buys insurance for financial security. When an injury or loss occurs, the claimant expects to receive treatment and compensation in a timely manner. Delivery on this is the heart of the claims function and process. Our Medical Claim Specialist carries out our promise of "Proudly Taking Care of Hawai`i" by working with injured workers to get the necessary care so that they can get back to work and life. Training will be provided.

Essential Duties

  • Manage medical only, lost time, and disfigurement claims. The assignment is based on the assessment and determination of the Manager. Training will be provided.
  • Review First report (WC- 1) for accuracy and completion.
  • Complete 24-hour three-point contact with Claimant, Employer, and Physician. Secure formal statements from injured workers as deemed appropriate.
  • Calculate average weekly wages and compensation rate. Issue timely indemnity benefits in compliance with H.R.S. 386.
  • Identify any potential third party (subrogation).
  • Process medical bills in compliance with Hawaii State Medical Fee Schedule and Claim Best Practices.
  • Develop and collaborate to implement claim strategies to facilitate case resolution.
  • Document and work within all Claim-related systems including but not limited to Guidewire, Image Right, My Matrix (Express Scripts), and IQ Review (AMC Bills).
  • Complete reinsurance reporting of financial exposures meeting the criteria ($250,000.00 and/or catastrophic).
  • Establish reserves based upon Probable Ultimate Cost.
  • Attend hearings before the Director as deemed appropriate by Claim Management and claim reviews on dedicated accounts as needed.
  • Maintain current diary.
  • Other duties as assigned.

Requirements

  • Basic understanding of workers’ compensation laws, rules, and regulations (preferred).
  • Current Hawaii Workers’ Comp Adjusters License (preferred).
  • Familiarity with medical and legal terminology (preferred).
  • Willingness to learn and develop professionally.
  • Excellent customer service skills, accuracy, attention to detail, and communication (written and verbal).
  • Ability to maintain confidential information.
  • Able to work independently as well as collectively as a team.
  • Proficiency with Microsoft Office Suite.
  • Self-directed and flexible.

Position title

Medical Claim Specialist

Department

Claim

Work Arrangement

In-Person, HEMIC Tower

Reports To

Manager, Claim

Direct Reports

N/A

FLSA Status

☒ Exempt ☐ Non-Exempt Job Class: 2-Prof

Approved By:

clewis

Date Approved:

4/23/2024

Reviewed:

N/A

NOTE: The above information on this job description has been designed to indicate the general nature and level of work performed by an employee in this classification. It is not to be interpreted as a comprehensive inventory, or all duties, responsibilities, and qualification of employees assigned to this job. Management has the right to add, revise or delete information in this description. Reasonable accommodations will be made to enable qualified individuals with disabilities to perform the essential duties of this position.

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