Job Description

Job Title: Technical Claims Specialist II
Job ID: 671578
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: Community HealthChoices
Location: 1650 Metropolitan Street, Pittsburgh PA 15233


Are you a health insurance professional with a strong background in claims adjustments?  If so, an opportunity as a Technical Claims Specialist II with UPMC Health Plan's Accumulator team may be the perfect fit for you. This role analyzes, and monitors reports, claims, and data to measure performance outcomes. Additionally, this role assists in research for department projects while providing technical and plan support to management team/business analyst.

  • Assist the department as requested during periods of backlogs
  • Complete special projects as assigned
  • Meets or exceeds established tasks timeframes/deadlines
  • Participate in the development/refinement of policies and procedures
  • Participates/partners in Quality Audit/training meetings for process improvement opportunities
  • Performs in accordance with system-wide competencies/behaviors
  • Process/adjust most sensitive; high profile inventories such as high dollar claims; accumulator adjustments
  • Provide weekly trending/work summary reports to management/Business Analyst team
  • Provides quality customer service to internal and external customers
  • Provides technical support and guidance to support the operations division's goals and objectives
  • Research and respond to both external and internal inquiries in a timely manner
  • Reviews, monitors, and researches claim data, issues, and/or reports
  • Serves as a Claims Operations representative at internal and external meetings
  • Serves as a process expert
  • Thorough understanding of standard to complex claims and adjustments
  • Understands client performance expectations and aligns assigned responsibilities accordingly
  • Working knowledge of McNet/Batch errors and resolution


  • High school graduate or equivalent required. College degree preferred.  
  • Three to five years health insurance, claims processing and/or customer service experience preferred. 
  • Knowledge of medical terminology, ICD-9 and CPT coding required. 
  • Knowledge of commercial, Medicaid, and Medicare products preferred. 
  • Competency in Microsoft Office with strong emphasis on Excel, Word, and Access. PC skills required. 
  • Ability to demonstrate organizational, interpersonal, and communication skills. 
  • Demonstrated analytical skills required. Ability to work independently with minimum direction. 
  • Ability to prioritize and perform multiple tasks to meet established deadlines. 
  • Extensive knowledge/experience with Coordination of Benefit determinations/investigation strongly preferred and a definite plus. 
  • Minimum of two years Coordination of benefits claim adjudication desired.
  • Knowledge of ICD-10 is highly preferred.
  • Previous medical health insurance experience highly preferred.
  • Previous health insurance claims experience is preferred.

Licensure, Certifications, and Clearances:
UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $18.24 to $30.32

Union Position: No

At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!


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