Job Description

Job Title: Provider Specialist I
Job ID: 620853
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day
Facility:
Department: Community HealthChoices
Location: 600 Grant St, Us Steel Tower Pittsburgh 15219

Description

Purpose:
Are you a health insurance professional with a strong claims and customer service background?  If so, an opportunity as a Provider Specialist I with UPMC Health Plan may be the perfect fit for you.  This role provides provider information maintenance to the master data repository and the transactional system(s) to aid directory/web productions and claims/1022/check/data processing. Additionally, ensure integrity of provider data for accurate claim adjudication, including PHI. Additional activities include ensuring the accuracy of electronically transmitted data for the purpose of releasing batch claims held for review. 

Responsibilities:
  • Accurately and efficiently updates data into the Mc400 system;
  • Collaborates with provider relations, customer, and/or vendors to evaluate and respond to requests, issues, and questions in a timely and professional manner;
  • Conducts ongoing entry and maintenance to in-network and out-of-network providers into the master data repository and transactional system(s)
  • Continuously searches for improvement opportunities and notifies the supervisor and/or team leader of trends;
  • Creates and maintain new networks in the data systems as needed;
  • Investigates via Filenet software or EDI (Electronic Data Interchange) Inquiry Screen(s) any flagged claims;
  • Maintains a thorough working knowledge of processes for electronically received data;
  • Notifies the supervisor and/or team leader of any issues that my compromise client satisfaction;
  • Protects the integrity and confidentiality of all provider data and information through physical and electronic measures;
  • Verifies electronically received data pre-adjudication;

Qualifications

  • High school diploma or equivalent required Bachelor's degree preferred.
  • Two years customer service and/or understanding of Medical claims administrative processes.
  • Knowledge of Insurance, Managed Care, or Benefits Administration environment preferred.
  • Medical provider billing, credentialing, and working knowledge of medical provider networks a plus.
  • Strong oral and written communication skills.
  • Professional demeanor with business phone etiquette.
  • Competent Microsoft Office (Excel a must)/PC Skills.
  • Able to demonstrate strong organizational and interpersonal skills.
  • Detail Oriented with strong emphasis on quality.
  • Maintain designated production and quality standards required.

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

Salary Range: $16.61 to $27.60

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!

QUALITY & SAFETY
DIGNITY & RESPECT
CARING & LISTENING
RESPONSIBILITY & INTEGRITY
EXCELLENCE & INNOVATION

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