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Provider Specialist I- CHC

  • Job ID: 291718650
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: CHC Claims Operation
  • Location: 600 Grant St, Pittsburgh PA 15219
  • Union Position: No
  • Salary Range: $17.97 to $29.87 / hour

Description


Provide provider information maintenance to the master data repository and the transactional system(s) to aid directory/web productions and claims/1022/check/data processing. Additionally, ensure integrity of provider data for accurate claim adjudication, including PHI. Additional activities include ensuring the accuracy of electronically transmitted data for the purpose of releasing batch claims held for review.

Responsibilities:
  • Accurately and efficiently updates data into the Mc400 system;
  • Maintains a thorough working knowledge of processes for electronically received data;
  • Notifies the supervisor and/or team leader of any issues that my compromise client satisfaction;
  • Protects the integrity and confidentiality of all provider data and information through physical and electronic measures;
  • Investigates via Filenet software or EDI (Electronic Data Interchange) Inquiry Screen(s) any flagged claims;
  • Creates and maintain new networks in the data systems as needed;
  • Collaborates with provider relations, customer, and/or vendors to evaluate and respond to requests, issues, and questions in a timely and professional manner;
  • Continuously searches for improvement opportunities and notifies the supervisor and/or team leader of trends;
  • Conducts ongoing entry and maintenance to in-network and out-of-network providers into the master data repository and transactional system(s)
  • Verifies electronically received data pre-adjudication;

Qualifications

  • High school diploma or equivalent required bachelor's degree preferred.
  • two years customer service and/or understanding of Medical claims administrative processes.
  • Knowledge of Insurance, Managed Care, or Benefits Administration environment preferred.
  • Medical provider billing, credentialing, and working knowledge of medical provider networks a plus.
  • Strong oral and written communication skills 
  • Professional demeanor with business phone etiquette 
  • Competent MS Office (Excel a must)/PC Skills
  • Able to demonstrate strong organizational and interpersonal skills
  • Detail Oriented with strong emphasis on quality
  • Maintain designated production and quality standards required.

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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