Claims Examiner - TPA/CCBH

UPMC; Pittsburgh (Allegheny County); Hybrid; USD 38,000 - 54,000; Full time

Job summary

UPMC Health Plan in the Pittsburgh area is seeking a Claims Examiner to manage adjudication of moderate to complex claims in a hybrid, full-time role.

You will work mostly remote with occasional office visits, support training, backlogged departments, ensure confidentiality, and meet production and quality standards while applying knowledge of medical terminology and coding.

Qualifications

• High school diploma or equivalent required or better.
• One year of claims processing experience preferred.
• Knowledge of medical terminology, ICD-9, and CPT coding.
• Knowledge of commercial, Medicaid, and Medicare products.
• Ability to use a QWERTY keyboard and basic computer skills.
• MS Office and PC skills preferred.
• Working knowledge of COB (Coordination of Benefits) preferred.
• Strong organizational, interpersonal, and communication abilities.
• Maintain production and quality standards.

Responsibilities

• Participate in training programs as available/requested.
• Assist other departments during periods of backlogs.
• Join team meetings and contribute ideas to ensure client satisfaction.
• Process OASNet/Batch Edit errors per standards.
• Maintain confidentiality of employee/insured information.
• Work overtime as required by business needs.
• Identify areas of concern affecting client satisfaction.
• Maintain mail date integrity.
• Process standard to moderate claims, including COB, timely and accurately.
• Resolve outstanding holds per standards.
• Prioritize and complete all assigned tasks.

Skills

Communication skills

Organizational skills

Interpersonal skills

Ability to prioritize

QWERTY keyboard

Education

High school diploma or equivalent

Tools

MS Office

PC skills

COB (Coordination of Benefits) knowledge

ICD-9/CPT coding knowledge

Job description

UPMC Health Plan has an exciting opportunity for a Claims Examiner position in the TPA CCBH Claims Operations department. This is a full-time hybrid position based in the Pittsburgh area. While you'll primarily work remotely, you'll come into the office occasionally depending on departmental needs. The Claims Examiner will manage adjudication of moderate to complex 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 OASNet/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

• Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran