Claims Examiner - Hybrid

UPMC Health Plan has an exciting opportunity for a Claims Examiner in the Operations department. This is a hybrid full-time position working Monday through Friday daylight hours. The Claims Examiner will manage adjudication of standard to moderate claims while meeting or exceeding production and quality designated standards.


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

• 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