Hybrid Claims Examiner - Health Plan Adjudication

UPMC; Pittsburgh (Allegheny County); Hybrid; USD 52,000 - 75,000; Full time

Job summary

UPMC Health Plan in Pittsburgh is seeking a Claims Examiner in the Operations department for a hybrid, full-time role working Monday through Friday daylight hours. The position focuses on adjudication of standard to moderate claims while meeting production and quality standards.

Responsibilities include participating in training, assisting during backlogs, supporting cross-department workflows, processing MCNet/Batch Edit errors, maintaining confidentiality, and prioritizing tasks to keep claims

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

Job description

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