Medical Only Claims Specialist II

UPMC • Pittsburgh, PA • 2d ago

UPMC Health Plan and WorkPartners is hiring a full-time Medical Only Claims Specialist II. This role will predominantly work remotely.

The UPMC WorkPartners Workers' Compensation Medical Only Claims Specialist II reports to the Workers' Compensation Supervisor. This is an intermediate level position within the Workers' Compensation Claims Department. The Medical Only Claims Specialist II 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 II will ensure claims are processed within company policies, procedures, and within individual's prescribed authority following established best practices and performance standards.

Responsibilities:

Establish appropriate reserves and review on a regular basis to ensure adequacy under supervision as necessary.

Determine validity and compensability of the claim independently.

Manage non-complex and non-problematic medical-only, restricted medical only, and limited lost time claims under some supervision.

Minor negotiations of claims for compromise and release

Investigate the claims through telephone, written correspondence, and/or personal contact with injured workers, insureds, witnesses and others having pertinent information.

Communicate claim status with the injured worker, insured, and broker as needed.

Adhere to client and carrier guidelines and participate in claims review as needed.

Receives claim, confirms policy coverage and acknowledgement of the claim

Establish reserves and authorize payments within authority limits.

Assists other claims professionals with more complex or problematic claims as necessary, which could include periodic handling of litigated cases

Participate in periodic claim reviews as needed.

Appropriate state licensing to be secured as needed.

Mentoring and training new employees as appropriately assigned by management.

Participate in monthly account renewal meetings as needed.

Bachelors and/or advanced degree OR a minimum of 2 years of administrative, claims, and/or customer service experience, preferably in Workers Compensation.

A minimum of 1 year of Workers Compensation medical only claim handling experience.

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:

Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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