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   Current UPMC employees must apply in HR Direct

Claims Examiner- Workers Compensation

Description

UPMC Health Plan is hiring a full-time Claims Examiner- Workers Compensation to help support the WorkPartners Claims Department. This is a Monday through Friday daylight position.

The successful candidate will investigate and analyze the information for a reported workers' compensation claim. Ongoing management of a medical only claim to include compensability determinations (restricted medical only and widow claims at the discretion of the claims supervisor). Provide customer service to injured workers, clients and providers.

Responsibilities:
  • Review invoice and medical records to determine eligibility for payment or denial of payment.
  • Evaluate, calculate and assign financial reserves to each claim and monitor ongoing exposure for reserve adjustments.
  • Utilize Nurse Case Manager and Medical Director on complicated medical issues.
  • Schedule surveillance/investigations when appropriate/applicable.
  • Maintain excellent relationship with clients.
  • Perform other duties as assigned by the supervisor and/or manager.
  • Provide clerical and technical support to the team to achieve operational goals.
  • Issuance of Bureau of Workers' Compensation documents throughout life of claim.
  • Customer service calls with client, injured employee, provider or attorney
  • Maintain employee confidentiality and privacy
  • Review claim for OSHA identification and reporting
  • Review daily validation and operational reports to manage case load.
  • Investigate claim to determine eligibility of workers' compensation benefits
  • Management and execution of action plans for each medical only claim (restricted medical only and widow at the discretion of claims supervisor) until claim closure or reassignment.
  • Tracking and documenting work loss and work restriction days
  • Participate in team meetings and provide ideas, suggestions and feedback to promote effective program management.
  • Prepare claim review report to present to client's quarterly outlining status of claim
  • Perform job duties and responsibilities in accordance to Work Partners Claims Management Standards
  • Contact client or departmental supervisor to discuss work accommodations.
  • Schedule Civil Service exams when work restrictions exceed 14 days upon release to return to full duty work on applicable accounts.
  • Schedule Independent Medical Evaluations when appropriate/applicable.
  • Maintain diary to follow activities of claim, appointments or deadlines.
  • Compensability determination for all medical only (restricted only claims at the discretion of supervisor).
  • Maintain clear, accurate and factual documentation of claim activities and plans of action.
  • Monitor ongoing medical treatment, work restrictions, disability and follow-up appointment after each exam with medical provider.
  • Schedule widow/dependency checks on applicable claims.

Qualifications

  • High School Graduate (college degree, professional certifications and licenses preferred).
  • Minimum 6-12 months clerical, claims or customer service experience. 
  • Prior Workers Compensation claims experience is preferred
  • Experience in workers' compensation, medical management and/or medical terminology preferred.
  • Proficiency in typing required
  • Proven organizational skills
  • Good written (grammar and punctuation) and verbal communication skills including the ability to communicate clearly and being a good listener via the telephone.
  • Customer Service oriented Organization skills
  • Detail oriented

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct

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