UPMC Health Plan and WorkPartners is hiring a full-time Medical Only Claims Specialist I to join the Workers Comp Claims team. This entry level role will work Monday - Friday daylight hours EST and may work remotely.
Employees living within 50 miles of our downtown Pittsburgh office are required to work on-site roughly once per month. For those residing outside this 50-mile radius, this is optional.
The UPMC WorkPartners Workers' Compensation Medical Only Claims Specialist 1 reports to the Workers' Compensation Supervisor. This is an entry level position within the Workers' Compensation Claims Department. The Medical Only Claims Specialist 1 is responsible for coverage analysis, investigation, evaluation, communication, and disposition of assigned medical claims within the WorkPartners Workers' Compensation business unit. The Medical Only Claims Specialist 1 will ensure claims are processed within company policies, procedures, and within individual's prescribed authority following established best practices and performance standards.
Responsibilities:
- Manage non-complex and non-problematic medical-only and restricted medical only, claims under close supervision.
- Additional duties as required. Appropriate state licensing to be secured as needed. Excellent communication skills.
- Adhere to client and carrier guidelines and special handling requests.
- Communicate claim status with the injured worker, insured/employer, and broker as needed.
- Prepare and present for insured/employer claim reviews outlining claims status and action plans with oversight from supervisor
- Receives claim, confirms policy coverage and acknowledgement of the claim
- Evaluate claim, calculate and establish appropriate reserves and review on a regular basis to ensure adequacy for exposure under close supervision.
- Establish reserves and authorize payments within authority limits.
- Investigate the claims through telephone, written correspondence, and/or personal contact with injured workers, insureds/employer witnesses and others having pertinent information.
- Review invoices and medical records to determine eligibility for payment or denial.
- Determine validity and compensability of the claim.
- Participate in periodic claim reviews as needed.
- Participate in monthly account renewal meetings as needed.
- Bachelors and/or advanced degree or a minimum of 1 year of administrative, claims, and/or customer service experience, preferably in Workers Compensation.
- Prior experience working in an office-based role strongly preferred.
- Demonstrated verbal and written communications skills.
- Demonstrated analytical and decision-making skills.
- Appropriate state licensing to be secured as needed. Excellent communication skills.
Licensure, Certifications, and Clearances:
UPMC is an Equal Opportunity Employer/Disability/Veteran