Claims Examiner - TPA/CCBH

About the role

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

Requirements

• High school graduate or equivalent required
• One year of claims processing and/or equivalent education preferred

Qualifications

• Knowledge of medical terminology, ICD-9, and CPT coding required
• Knowledge of commercial, Medicaid, and Medicare products
• Working knowledge of COB (Coordination of Benefits) preferred

Skills

• Ability to use a QWERTY keyboard
• Competent in MS Office and PC skills preferred
• Ability to demonstrate organizational, interpersonal, and communication skills
• Maintain designated production and quality standards required

Schedule