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Are you someone who enjoys solving problems, helping others, and working with purpose? As a Direct Member Reimbursement Claims Service Specialist I at UPMC Health Plan, you'll be at the heart of our commitment to delivering exceptional service to our members.

In this role, you'll be the go-to expert for resolving member-submitted claims-ensuring every detail is accurate, every interaction is compassionate, and every claim is handled with care. You'll work directly with members and providers, guiding them through the claims process, requesting missing documentation, and making sure all claims meet our quality and compliance standards.

As the DMR Claims Service Specialist, you are a trusted resource for our members, helping them understand their benefits, and making sure their claims are processed smoothly and fairly. You'll be actively engaged on the phone system during your scheduled hours, ready to answer questions, conduct research, and provide clear, empathetic support.

What You'll Be Doing:

+ Process a variety of DMR claims-including Foreign, Cruise Ship, Lamaze, Flu Shot, Gym Membership, and Out-of-Network claims-with accuracy and efficiency.

+ Manually enter claim data into our systems, ensuring all information is complete and correct.

+ Communicate with members and providers via phone, email, and fax to request missing documentation and resolve inquiries.

+ Respond to incoming calls with professionalism and empathy, guiding members through the claims process and benefit details.

+ Maintain and update documentation in systems like FileNet and MC400, ensuring data integrity and compliance.

+ Send timely correspondence such as Subscriber Acknowledgement and Delay letters, and escalate issues when needed.

+ Stay current on departmental policies, procedures, and benefit designs to provide accurate information.

+ Participate in team meetings and training, offering ideas and solutions to improve service and efficiency.

+ High school diploma or equivalent required Bachelor's degree preferred

+ Minimum of 2 years' health insurance; claims processing and/or customer service experience preferred

+ Able to use a QWERTY keyboard

+ Knowledge of Insurance, Managed Care, or Benefits Administration environment preferred

+ Knowledgeable in medical terminology, ICD-10 and CPT coding required

+ Competent in MS Office with strong emphasis on Excel, Word, and Access.

+ PC skills required

+ Knowledge of Commercial, Medicaid, and Medicare products preferred

+ Strong interpersonal skills with good verbal and written communication to internal and external clients.

+ This will incorporate call handling skills when required.

+ Must possess excellent attention to detail, with a high level of accuracy.

+ Maintain designated production and quality standards required.

+ Ability to prioritize and perform multiple tasks to meet established deadlines.

+ Confident in making decisions and exercise judgment where necessary.

+ Strong customer focus with ability to identify and solve problems.

+ Must be flexible with responsibilities and have an exceptional ability to multitask.

+ Ability to work independently.Licensure, Certifications, and Clearances:UPMC is an Equal Opportunity Employer/Disability/Veteran