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Purpose:

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 need

+ 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

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.

+ Ability to use a QWERTY keyboard.

+ Competent in MS Office and PC skills preferred.

+ Working knowledge of COB (Coordination of Benefits) preferred.

+ Ability to demonstrate organizational, interpersonal, and communication skills.

+ Maintain designated production and quality standards required.

+ Previous computer experience in a professional setting is highly preferred. **Licensure, Certifications, and Clearances:** **UPMC is an Equal Opportunity Employer/Disability/Veteran**