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   Current UPMC employees must apply in HR Direct

DMR Claims Service Spclst I


The DMR Claims Service Specialist I is responsible for the resolution of Health Plan Subscriber submitted claims while meeting or exceeding the designated production and quality standards. The DMR Claims/Service Specialist I validates the information on all medical claims submitted by UPMC Health Plan members seeking out of network reimbursement. Responsibilities include thoroughly reviewing claims to ensure there is no missing or incomplete information, manually entering claims into the claims processing system and complete outreaches to members or providers requesting all missing documentation. In addition, the DMR Claims/Service Specialist I must provide exceptional customer service while responding to inbound or outbound member calls regarding interpretation and education on claims processing outcome.

Due to COVID-19 circumstances, this position will temporarily work remotely. This role is eligible for long-term partial work from home privileges, after successful completion of orientation and training (privilege eligibility is subject to continued achievement of business goals and on-site department needs).
  • Remain current on all departmental policies, procedures, plan benefit designs, and modificationsPerform other duties as identified and assigned
  • 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 confidentialityParticipate 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.


  • High school diploma or equivalent required 
  • Bachelor's degree preferred;
  • Minimum of 2 years' health insurance; claims processing and/or customer service experience preferred;
  • Able to use a QWERTY keyboard;
  • Knowledge of Insurance, 
  • Managed Care, or Benefits Administration environment preferred;
  • Knowledgeable in medical terminology, ICD-10 and CPT coding required;
  • Competent in MS Office with strong emphasis on Excel, Word, and Access. PC skills required;
  • Knowledge of Commercial, Medicaid, and Medicare products preferred;Skills: Strong interpersonal skills with good verbal and written communication to internal and external clients. 
  • This will incorporate call handling skills when required. 
  • Must possess excellent attention to detail, with a high level of accuracy. 
  • Maintain designated production and quality standards required. 
  • Ability to prioritize and perform multiple tasks to meet established deadlines. Confident in making decisions and exercise judgment where necessary. 
  • Strong customer focus with ability to identify and solve problems.
  • Must be flexible with responsibilities and have an exceptional ability to multitask.
  • Ability to work independently.

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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