Remote Case Investigator Jobs in Virginia (NOW HIRING)

Company Details

Berkley Medical Management Solutions (BMMS) provides a different kind of managed-care service for W.R. Berkley Corporation. We believe focusing on an injured worker's successful and speedy return to work is good for people and good for Berkley's insurance operating units. BMMS was first started in 2014 by reimagining the relationship between medical need and technology as a way to deliver the best outcome for injured workers and Berkley's operating units. Our goal was clear: combine solid clinical practices, proven return-to-work strategies and robust software into one system for seamless management of workers' compensation cases.

To get it right, we started with a flexible technology platform that allowed for impressive customization without sacrificing the ability for expansion and continued innovation. We deploy integrated systems to give W.R. Berkley Companies recommendations and professional services for managing each individual case in an efficient and appropriate manner. The power of our technology takes medical bill-review services and clinical advisory services to a new level. Our unique marriage of technology, software platforms, data analytics and professional services ensures we provide Berkley's operating units with reliable results, and reduced time and expenses associated with case management.

Responsibilities

The position serves as a subject-matter expert for Medical Bill Review (MBR) operations, providing advanced production support, driving process improvements, and coordinating cross-functional issue resolution and project execution. As an Operations Analyst, you will support the processing of workers' compensation medical and pharmacy bills from bill intake through bill payment and is a primary resource for issue resolution related to these processes. You will work directly with Berkley Operating Units to investigate bill processing issues and are responsible for problem-solving, identifying and triaging issues to technical teams, directly interfacing with multiple vendors to facilitate issue resolution, issue documentation, tracking, and reporting. You may also work directly with medical providers and networks regarding billing issues. We'll also look to you to independently and as part of a team identify issue commonalities and root causes to assist in solution design, monitoring, and controlling.

The position serves as a subject-matter expert for Medical Bill Review (MBR) operations, providing advanced production support, driving process improvements, and coordinating cross-functional issue resolution and project execution. Core responsibilities include:

MBR Production Support & Issue Resolution

• Serve as the primary escalation point for complex MBR issues that cannot be resolved by Operations Technician/Level 1 support, vendors, or related internal teams (Clinical Validation, Negotiations, OU adjusters, mailroom).
• Diagnose operational and adjudication issues by applying deep MBR process knowledge and collaborating with vendors and internal partners to resolve root causes.
• Provide backup Level 1 support, including bill-level troubleshooting, Jira ticket creation/maintenance, report distribution, and vendor communications.
• Maintain timely, clear communication with Operating Units, providers, and stakeholders regarding issue status, outcomes, and required actions.

Operational Analysis, Monitoring & Continuous Improvement

• Monitor business dashboards and vendor reports daily to identify and escalate adverse bill TAT trends, identify likely root cause owners, and track resolution progress.
• Recommend workflow enhancements, rule updates, and process changes to improve MBR accuracy, efficiency, and throughput.
• Document trends, issues, and resolutions to support auditability and continuous operational improvement.

Cross-Functional Collaboration

• Work closely with BMMS IT, BAMTECH, BTS, Finance, Data Reporting, and MBR vendors to coordinate root cause investigations, technical fixes, and operational adjustments.
• Support Operating Unit staff by analyzing medical bill issues, guiding next steps, and ensuring a consistent, professional experience.
• Build and maintain strong relationships with internal teams, external vendors, clients, and medical providers.

Project Leadership

• Serve as the lead business resource for regulatory audit responses, coordinating data gathering, vendor input, and documentation review prior to submission.
• Lead reconsideration projects, including impact analysis, bill resubmission coordination, and monitoring outcomes.
• Partner with Business Analysts on MBR-related initiatives such as API implementations, vendor transitions, mailroom integrations, and payment process enhancements.

Professional Standards & Administration

• Manage assignments in alignment with standard operating procedures, meeting requirements, and departmental expectations.
• Maintain issue tracking and ensure timely escalation of complex matters.
• Demonstrate professionalism, tact, and discretion in all interactions, contributing positively to department morale and organizational reputation.

Qualifications

• MBR business process SME including experience with MBR E2E process from a business/operations perspective; firm understanding of integrated services and workflows including FS/UCR, Nurse and code review, PPO, negotiations, adjustor bill adjudication; workers compensation regulatory environment experience/understanding;
• Demonstrated application of successful critical thinking and complex problem solving skills;
• Experience in a role requiring deep understanding of and experience working with MBR and integrated services technology - not at a developer level - but from a business analyst perspective;
• Experience gathering business requirements and clearly documenting complex scenarios and use cases to communicate MBR issues accurately for resolution;
• Communication experience with varied audiences including leadership and peers in business/operational & technology roles;
• Client-facing acumen
• Team-player
• Experience with Atlassian/JIRA/SQL
• 5 years in a multi-faceted workers compensation MBR role demonstrating increasing responsibility with required skills outlined above within that time
  • or 3 years in an MBR role + 2 years in position with similar responsibilities;

Additional Company Detailswww.berkleymms.com The Company is an equal employment opportunity employer We do not accept any unsolicited resumes from external recruiting agencies or firms. The company offers a competitive compensation plan and robust benefits package for full time regular employees Base Salary Range: 75k - 95k Benefits: Health, Dental, Vision, Life, Disability, Wellness, Paid Time Off, 401(k) and Profit-Sharing plans. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment.Additional Requirements Domestic U.S. travel required (up to 5% of time)Sponsorship DetailsSponsorship not Offered for this RoleEmployment Type: OTHER