Claims Examiner (CHC/Medicaid)

UPMC Health Plan is hiring full-time Claims Examiners to support our CHC/Medicaid Claims Department in the Pittsburgh area!

The Claims Examiners will work daylight shifts within the hours of 6 a.m. to 5 p.m., Monday through Friday! This role is fully remote, with the exception of occasional required in-office days for trainings, meetings, and other departmental needs.

In this position, you will manage the adjudication of moderate to complex claims while meeting or exceeding production and quality-designated standards. Our objective is to work to give members a better quality of life, and studies have shown that people generally do better if they’re able to stay in their homes and communities.

Responsibilities:

Participate in training programs, as available/requested.

Assist other departments during periods of backlogs.

Openly participate in team meetings, provide ideas and suggestions to ensure client satisfaction, and promote teamwork.

Process MCNet/Batch Edit errors in accordance with designated standards.

Maintain employee/insured confidentiality.

Work overtime, as required per business needs.

Identify areas of concern that may compromise client satisfaction.

Maintain mail date integrity.

Process standard-to-moderate claims, including COB, in accordance with company policies and procedures in a timely manner, while meeting or exceeding production and quality standards.

Resolve outstanding holds in accordance with designated standards.

Effectively prioritize and complete all assigned tasks.

High School graduate or equivalent required.

One year of claims processing and/or equivalent education preferred.

Knowledge of medical terminology, ICD-9, and CPT coding required.

Knowledge of Commercial, Medicaid, and Medicare products.

Typing proficiency.

Competency in Microsoft Office and computer skills preferred.

Working knowledge of COB (Coordination of Benefits) preferred.

Ability to demonstrate organizational, interpersonal, and communication skills.

Ability to maintain designated production and quality standards required.

Previous computer experience in a professional setting is highly preferred.

Licensure, Certifications, and Clearances:

Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran