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UPMC Health Plan and WorkPartners is hiring a Medical Only Claims Specialist 1! Following completion of training this role may work predominantly remotely but will require occasional in office attendance in downtown Pittsburgh. Candidates without previous Workers Compensation claims experience should reside locally for in person training.

The UPMC WorkPartners Workers' Compensation Medical Only Claims Specialist 1 reports to the Workers' Compensation Supervisor. This is an entry level position within the Workers' Compensation Claims Department. The Medical Only Claims Specialist 1 is responsible for coverage analysis, investigation, evaluation, communication, and disposition of assigned medical claims within the WorkPartners Workers' Compensation business unit. The Medical Only Claims Specialist 1 will ensure claims are processed within company policies, procedures, and within individual's prescribed authority following established best practices and performance standards.

Responsibilities:

+ Manage non-complex and non-problematic medical-only and restricted medical only, claims under close supervision.

+ Additional duties as required. Appropriate state licensing to be secured as needed.

+ Excellent communication skills.

+ Adhere to client and carrier guidelines and special handling requests.

+ Communicate claim status with the injured worker, insured/employer, and broker as needed.

+ Prepare and present for insured/employer claim reviews outlining claims status and action plans with oversight from supervisor

+ Receives claim, confirms policy coverage and acknowledgement of the claim

+ Evaluate claim, calculate and establish appropriate reserves and review on a regular basis to ensure adequacy for exposure under close supervision.

+ Establish reserves and authorize payments within authority limits.

+ Investigate the claims through telephone, written correspondence, and/or personal contact with injured workers, insureds/employer witnesses and others having pertinent information.

+ Review invoices and medical records to determine eligibility for payment or denial.

+ Determine validity and compensability of the claim.

+ Participate in periodic claim reviews as needed.

+ Participate in monthly account renewal meetings as needed.

+ Bachelors and/or advanced degree or a minimum of 1 year of administrative, claims, and/or customer service experience, preferably in Workers Compensation.

+ Demonstrated verbal and written communications skills.

+ Demonstrated analytical and decision making skills.

+ Appropriate state licensing to be secured as needed.

+ Excellent communication skills. **Licensure, Certifications, and Clearances:**

+ Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran