Claims Examiner

About This Role

This full-time Claims Examiner role supports the Claims Operations Department by reviewing provider-submitted claims to determine eligibility for payment or denial. The position ensures accuracy, timeliness, and compliance with UPMC's standards, helping members receive care and providers receive efficient claims processing. It is a hybrid position with in-office presence required for trainings, team meetings, and departmental collaboration.

Responsibilities

• Process standard-to-moderate claims, including coordination of benefits (COB), in accordance with company policies and procedures
• Resolve outstanding holds and ensure claims are completed within designated timelines
• Support other departments during peak periods or backlogs
• Participate in team meetings and training programs, sharing ideas and promoting teamwork
• Maintain confidentiality of members and employee information
• Identify and escalate issues that may impact client satisfaction
• Work overtime as needed based on business demand
• Stay organized and proactive, prioritizing tasks and maintaining productivity and quality standards

Requirements

• High school graduate or equivalent
• Knowledge of medical terminology, ICD-9, and CPT coding
• Knowledge of commercial, Medicaid, and Medicare products
• Ability to use a QWERTY keyboard
• Ability to demonstrate organizational, interpersonal, and communication skills
• Maintain designated production and quality standards
• ACT 34

Nice to have:

• One year of claims processing and/or equivalent education
• Competent in MS Office and PC skills
• Working knowledge of COB (Coordination of Benefits)

Benefits

• Daylight schedule: Monday through Friday between 6:00 AM and 4:30 PM, no mandatory evenings or weekends
• Collaborative environment
• Mission-driven work

About the Company

UPMC Health Plan is a mission-driven organization that supports the health and wellbeing of thousands.