Claims Examiner

at  UPMC

UPMC Health Plan is seeking a full-time Claims Examiner to support the Medicare & Commercial Claims teams within the Claims Operations Department!
The Claims Examiner will work daylight shifts between the hours of 6 a.m. and 4:30 p.m., Monday through Friday. No mandatory evenings or weekends are required! This role is fully remote, with the exception of occasional required in-office days for trainings, meetings, and other departmental needs.
The Claims Examiner manages the adjudication of moderate-to-complex claims while meeting or exceeding production and quality designated standards. The Medicare and Commercial Claims teams have an established remote work culture and numerous opportunities for professional growth!

• 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.
• Maintain employee/insured confidentiality.
• Work overtime, as required per business need.
• Identify areas of concern that may compromise client satisfaction.
• 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.
• Typing proficiency.
• Competency in Microsoft Office and computer skills preferred.
• Working knowledge of COB (Coordination of Benefits) preferred.
• Ability to demonstrate organizational, interpersonal, and communication skills.
• Ability to maintain designated production and quality standards required.