Claims Examiner- Medicare/Commercial

Are you detail-oriented, organized, and looking for a role where your work truly makes a difference? UPMC Health Plan is hiring a full-time Claims Examiner to support our Claims Operations Department.


As a Claims Examiner, you'll play a key role in reviewing provider-submitted claims to determine eligibility for payment or denial-ensuring accuracy, timeliness, and compliance with UPMC's standards. Your work helps ensure our members receive the care they need and our providers are supported with efficient, reliable claims processing.


This is a hybrid position, with in-office presence required based on business needs such as trainings, team meetings, and departmental collaboration.


Why You'll Love This Role:

• Daylight Schedule: Work Monday through Friday between 6:00 AM and 4:30 PM-no mandatory evenings or weekends!
• Collaborative Environment: Be part of a supportive team that values your input and ideas.
• Mission-Driven Work: Your attention to detail helps ensure our members and providers receive the service they deserve.

What You'll Be Doing:

• Process standard-to-moderate claims, including coordination of benefits (COB), in accordance with company policies and procedures.
• Resolve outstanding holds and ensure claims are completed within designated timelines.
• Support other departments during peak periods or backlogs.
• Participate in team meetings and training programs, sharing ideas and promoting teamwork.
• Maintain confidentiality of member and employee information.
• Identify and escalate issues that may impact client satisfaction.
• Work overtime as needed based on business demand.
• Stay organized and proactive, prioritizing tasks and maintaining productivity and quality standards.

Who We're Looking For:

• You're a problem-solver who enjoys working independently and as part of a team.
• You're comfortable in a fast-paced environment and managing multiple tasks.
• You take pride in accuracy and understand the importance of compliance and confidentiality.
• You're ready to grow your career with a mission-driven organization that values your contributions.

If you're ready to bring your attention to detail and commitment to excellence to a team that supports the health and well-being of thousands, apply today and become part of something bigger at UPMC Health Plan.

Qualifications:

• 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.
  Licensure, Certifications, and Clearances:
  UPMC is an Equal Opportunity Employer/Disability/Veteran