Medical Only Claims Specialist I - Workers Comp

UPMC • Pittsburgh, PA • 5h ago

UPMC Health Plan and WorkPartners is hiring a full-time Medical Only Claims Specialist I to join the Workers Comp Claims team. This entry level role will work Monday - Friday daylight hours EST and may work remotely.

Employees living within 50 miles of our downtown Pittsburgh office are required to work on-site roughly once per month. For those residing outside this 50-mile radius, this is optional.

The UPMC WorkPartners Workers' Compensation Medical Only Claims Specialist 1 reports to the Workers' Compensation Supervisor. This is an entry level position within the Workers' Compensation Claims Department. The Medical Only Claims Specialist 1 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 individual's prescribed authority following established best practices and performance standards.

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.

Participate in periodic claim reviews as needed.

Participate in monthly account renewal meetings as needed.

Bachelors and/or advanced degree or a minimum of 1 year of administrative, claims, and/or customer service experience, preferably in Workers Compensation.

Prior experience working in an office-based role strongly preferred.

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

UPMC

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