Job Description

Job Title: Reimbursement Specialist
Job ID: 691824
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 Reimbursement Specialist! This person will manage all aspects of provider reimbursement; this includes establishing and maintaining compensation rates for hospitals, physicians, and ancillary services.

This department negotiates rates that are paid to all medical providers. There is a lot of data analysis to determine the impact of provider proposals and rate changes. Senior management will often look to the department to determine the financial impact of proposed initiatives.


Preferences are as follows: Excel proficiency , healthcare background.


Apply today!


  • Act as company expert on all reimbursement issues.
  • Analyze all reimbursement, including outliers, transfer adjustments, etc.
  • Analyze and compare fee schedules.
  • Attend meetings when required
  • Complete special projects accurately and timely.
  • Develop and negotiate reimbursement rates for new providers. Include accurate, easy to understand analysis of the negotiated rates.
  • Monitor Calendar to assure all action items are completed proactively.
  • Monitor and review new pricing configuration to assure the provider's claims are pricing accurately and as contracted. This includes maintaining documentation of your review.
  • Out of network negotiations when required.
  • Renegotiate contracts when requested or contractually required.
  • Resolve problems that result in claims pending.
  • Resolve reimbursement issues.
  • Update and maintain hospital reimbursement rate summary.
  • Update and maintain hospital reimbursement reports for all product lines. Report include inpatient base rate comparisons, outpatient reimbursement comparisons to UPMC OP fee schedule, Observation cost per case.
  • Work with Network Development in establishing network goals and priorities. Report any issue that may prevent a provider from signing by the network development goal date.
  • Work with UM department on special UM reimbursement initiatives. Provide accurate analysis and expert reports to assist UM in making a decision in a proposed program.
  • Work with configuration staff when negotiating to assure negotiated rates are operational.


  • B.A. degree in health care administration, business and/or other related discipline (Related experience may be substituted for educational requirements).
  • Masters Degree preferred.
  • Five-ten years experience with either a physician practice, hospital, ancillary provider, health insurance company or integrated delivery system is required.
  • Individual needs to have in depth understanding of managed care delivery systems and have had direct experience with reimbursement.
  • Excellent planning, communication, documentation, organizational, analytical, and problem solving abilities.
  • Advanced mathematical skills.
  • Ability to interpret and summarize results of various analysis in a timely and meaningful way.
  • Strong computer skills, including expert knowledge of Access and Excel.
  • Knowledge of ICD-9CM, CPT4, Revenue Codes, DRGs, base rates, Medicare methodologies, Medicaid methodologies, HCPCS coding and related governmental guidelines and provider reimbursement methodologies required.
  • Knowledge of fee schedules, case rates, per-diems, RUG III.
  • Ability to work cooperatively with multidisciplinary teams and/or independently.
  • Ability to re-engineer processes to positively impact productivity in terms of timeliness and accuracy.
  • Ability to furnish finished reports.

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

Salary Range: $26.64 to $44.88

Union Position: No

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