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Medical Only Claims Specialist I

  • Job ID: 348204555
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: WKP Comm WC Claims Admin
  • Location: 600 Grant St, Pittsburgh PA 15219
  • Union Position: No
  • Salary Range: $19.41 to $32.25 / hour

Description

The UPMC WorkPartners Workers' Compensation Medical Only Claims Specialist I reports to the Workers' Compensation Supervisor. This is an entry-level position within the Workers' Compensation Claims Department. The Medical Only Claims Specialist I is responsible for coverage analysis, investigation, evaluation, communication, and disposition of assigned medical claims within the WorkPartners Workers' Compensation business unit. The Medical Only Claims Specialist 1 will ensure claims are processed within company policies, procedures, and within the individual's prescribed authority following established best practices and performance standards.

This position is a Monday through Friday, daylight position that allows work-from-home at leadership's disrection. 

Up for the challenge? Apply today!

Responsibilities:

 

  • Manage non-complex and non-problematic medical-only and restricted medical only, claims under close supervision.
  • Additional duties as required.Appropriate state licensing to be secured as needed.Excellent communication skills.
  • Adhere to client and carrier guidelines and special handling requests.
  • Communicate claim status with the injured worker, insured/employer, and broker as needed.
  • Prepare and present for insured/employer claim reviews outlining claims status and action plans with oversight from supervisor
  • Receives claim, confirms policy coverage and acknowledgement of the claim
  • Evaluate claim, calculate and establish appropriate reserves and review on a regular basis to ensure adequacy for exposure under close supervision.
  • Establish reserves and authorize payments within authority limits.
  • Investigate the claims through telephone, written correspondence, and/or personal contact with injured workers, insureds/employer witnesses and others having pertinent information.
  • Review invoices and medical records to determine eligibility for payment or denial.
  • Determine validity and compensability of the claim.

 

Qualifications

  • Bachelor's and/or advanced degree (One year of Property & Casualty claims handling experience, preferably in Workers' Compensation, will be considered in lieu of degree)
  • Demonstrated verbal and written communications skills.
  • Demonstrated analytical and decision making skills.
  • Appropriate state licensing to be secured as needed.Excellent communication skills.


Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct