DMR Claims Service Specialist I

The DMR Claims Service Specialist I is responsible for the resolution of Health Plan Subscriber submitted claims. In this role you will validate the information on all medical claims submitted by UPMC Health Plan members seeking out of network reimbursement. You will thoroughly review claims to ensure there is no missing or incomplete information, manually enter claims into the claims processing system and complete outreaches to members or providers requesting all missing documentation. You must also provide exceptional customer service while responding to inbound or outbound member calls regarding interpretation and education on claims processing outcome.

Responsibilities:

• Remain current on all departmental policies, procedures, plan benefit designs, and modifications
• Conduct outbound calls to request missing documentation, clarify follow up and resolve inquiries from customers regarding Direct Member Reimbursement claims.
• Investigate, document, and bring to resolution, all customer inquiries in accordance with Health Plan Subscriber Submitted Claims guidelines.
• Maintain and update FileNet correspondence for all Direct Member Reimbursement claim types.
• Answer incoming inquiries from UPMC Health Plan members regarding Direct Member Reimbursement Claims.
• Maintain employee and insured confidentiality
• Participate in training programs as available/requested;
• Process moderate to complex Direct Member Reimbursement claims, including Foreign, Cruise Ship, Lamaze, Flu Shot, Gym Membership and Pay to Provider Out of Network Claims, in accordance with company policies and procedures in a timely manner while meeting or exceeding production and quality standards.
• Accurately and efficiently manually keys OCR Rejection claim data into the MC400 system.
• Document inquiries in accordance with UPMC Customer Service Center guideline.
• Submit Subscriber Acknowledgement and Delay letters according to claims timeliness guidelines
• Review correspondence submitted by members and providers and process all related claims if the additional documentation submitted warrants processing/adjustments.
• Actively maintain worklist open cutlogs and follow up within the designated time standards.
• Escalate issues and concerns in a timely fashion.Actively participate in departmental meetings, offer suggestions and resolutions related to current issues.