MEDICAL CLAIM SPECIALIST

Posted: 01/09/2022

POSITION SUMMARY
Manage workers’ compensation medical only, limited time loss and disfigurement claims in compliance with Hawaii Revised Statutes (H.R.S.) and related Administrated Rules, as well as HEMIC’s Claim Best Practices.  Responsible for documentation in all claims related systems. Attend hearings before the Director of the Department of Labor and Industrial Relations as deemed appropriate by Claim Management.  Works within a team concept by dedicated Unit, with heavy focus on customer service.  Participate in claim reviews as needed.  Timely process workers’ compensation medical and indemnity benefits.

ESSENTIAL DUTIES

  • Review First report (WC- 1) for accuracy and completion.
  • Manage medical only, lost time and disfigurement claims. The assignment is based upon the assessment and determination of the Claims Manager.
  • Complete 24-hour three-point contact to 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 implement claim strategies to facilitate case resolution. This may also include limited Triage and or TCM collaboration.
  • Document and work within all Claims related systems to include 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).
  • Establishes reserves based upon Probable Ultimate Cost.   
  • Attend hearings before the Director as deemed appropriate by Claim Management.
  • Attend claim reviews on dedicated accounts as needed.
  • Maintain current diary
  • Other duties as assigned.
QUALIFICATIONS
  • Basic understanding of workers’ compensation laws, rules and regulations preferred.
  • Current Hawaii Workers’ Comp Adjusters License.
  • Medical and legal terminology a plus.
  • Excellent customer service skills.
  • Maintains high level of accuracy.
  • Ability to maintain confidential information.
  • Able to work independently as well as collectively as a team.
  • Excellent verbal and written skills.
  • Microsoft proficient preferred.
  • Strong attention to detail.
  • Self-directed and flexible.