Claims Examiner

About the role

UPMC Health Plan is hiring a full-time Claims Examiner to support the Claims Operations Department. In this role, you will review provider-submitted claims to determine eligibility for payment or denial, ensuring accuracy, timeliness, and compliance with UPMC's standards. Your work helps ensure members receive the care they need and providers are supported with efficient, reliable claims processing. This is a hybrid position requiring in-office presence for trainings, team meetings, and departmental collaboration based on business needs.

Schedule

Full-time, Monday through Friday, 6:00 AM to 4:30 PM (daylight schedule). No mandatory evenings or weekends. Overtime may be required based on business demand.

Responsibilities

• 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.

Requirements

• High school graduate or equivalent required.
• One year of claims processing experience 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.
• Competency in MS Office and PC skills preferred.
• Working knowledge of COB (Coordination of Benefits) preferred.
• Strong organizational, interpersonal, and communication skills.
• Ability to maintain designated production and quality standards.

Qualifications

• Problem-solver who enjoys working independently and as part of a team.
• Comfortable in a fast-paced environment managing multiple tasks.
• Takes pride in accuracy and understands the importance of compliance and confidentiality.
• Ready to grow career with a mission-driven organization.

Licensure & Clearances

ACT 34 clearance required.

Benefits

• Collaborative, supportive team environment that values input and ideas.
• Mission-driven work ensuring members and providers receive quality service.
• Daylight schedule with no mandatory evenings or weekends.