Job Description

Job Title: Senior Reimbursement Specialist
Job ID: 680104
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: HPLAN - Hospital Reimbursement
Location: 600 Grant St, Pittsburgh PA 15219


UPMC Health Plan is seeking a Senior Reimbursement Specialist! The Senior Reimbursement Specialist is a high level professional position with expanded responsibilities within the Reimbursement Department.


Included in the daily responsibilities is the supervision of designated department personnel in order to expedite claim issue resolution, continuing to streamline processes associated with manual claims pricing, and working with other departments in order to insure claims pricing accuracy going forward. This position will report directly to the department manager with associated results and any issues requiring managerial guidance or intervention.


The Senior Reimbursement Specialist will also be involved with special projects requiring financial analysis associated with hospital reimbursement and contract negotiation. Included in these special projects is development of fee schedules, case rates, per diems, and reimbursement modeling that may require discussion and / or negotiation at the provider level.


  • Ability to devise alternative reimbursement strategies for all provider types.
  • Act as a department liaison for strategies and process improvement plans regarding provider communications.
  • Analyze and summarize provider issues for Executive Management.
  • Assist with HP vendor relations involving meetings, financial data reporting, and payments.
  • Attend meetings requiring representation by reimbursement department, including external meetings with hospital representatives or officers.
  • Communications with all provider types in order to resolve claims issues including reimbursement, coding, and system configuration.
  • Complete special projects for the department as needed.
  • Develop, manage, and maintain projects for provider communications.
  • Educate PHOs, hospitals, and physicians on reimbursement strategies.
  • Establish reimbursement schedules for hospital, physician and ancillary providers. These schedules have to be competitive in the market and actuarially sound, based on the premiums being offered to insured members.
  • Identify issues involving documentation, coding and billing to improve efficiency and effectiveness of practice management.
  • Interacts with PHOs, hospitals, and physician departments to resolve claim issues and fee schedule questions.
  • Maintain, update, and submit Network's Policies & Procedures (P&P).
  • Managing the daily workload of all pended claims and claims issues received from outside of the reimbursement department.
  • Negotiate OON/OOA services provided to members.
  • Oversee the maintenance of fee schedules for updates, distributions, and retention.
  • Participate in the design and implementation of reimbursement models for PHOs, POs, and Providers.
  • Provide on-going analysis and comparison of reimbursement schedules to insure market competitiveness.
  • Provide reimbursement data necessary to process claims for members of the Health Plan or resolve claims issues
  • Special projects as required, utilizing claims system knowledge and spreadsheet applications incorporating advanced use of Excel and / or Access.
  • Supervision of designated departmental personnel to address all claims issues including, problem resolution, rate configuration while considering system limitations, claims pending and manual pricing, and the incorporation of process efficiencies when applicable.


  • Bachelors Degree is required.
  • Masters Degree preferred.
  • Seven years experience with a physician practice, hospital, ancillary provider, health insurance company or integrated delivery system is required.
  • Individual needs to have a strong understanding of reimbursement and associated methodologies, and experience with problem resolution at the individual claim level.
  • Knowledge of ICD-9, CPT-4 and HCPCS coding and related governmental guidelines and provider reimbursement methodologies required.
  • Experience with various claim types, systemic pricing methods, and appropriate configuration methods to ensure claim accuracy.
  • Excellent written and verbal communication skills and the ability to supervise others. Strong organizational skills and ability to prioritize projects.
  • Good working knowledge of the claims pricing system and the ability to research and resolve issues.
  • Proficient at utilizing PC based system applications and have the ability to create complex spreadsheets for purposes of financial analysis.
  • Documented proficiency in Microsoft Excel and Access are required for this position..

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

Salary Range: $28.37 to $47.88

Union Position: No

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