Adjuster I

Claims Operations Specialists

We are seeking highly skilled Claims Operations Specialists to join our dynamic team. This role is responsible for processing medical claim adjustments and resolving discrepancies across multiple lines of business for the Health Plan. The ideal candidate will handle a range of requestsfrom standard to complexwith precision and efficiency, contributing to the overall accuracy and integrity of our claims processing operations.

This position will work a hybrid structure, reporting to the office as needed.

Responsibilities:

• Process standard to complex claims and adjustments in a timely manner (project reports, claim adjustment pends, corrected claims, CUT logs) according to designated standards, while meeting or exceeding production and quality goals.
• Successfully complete special projects within designated standards.
• Collaborate with leadership and other internal and external customers to resolve claim adjudication and adjustment issues.
• Assist with entry/adjudication of claim testing.
• Resolve outstanding items in accordance with designated standards.
• Maintain employee/insured confidentiality.
• Manage multiple priorities according to designated standards.
• Participate in training programs.
• Openly participate in team meetings and offer ideas and suggestions to ensure client satisfaction and promote teamwork.
• Assist with department or other department backlogs as needed.
• Work department overtime as required per business need.
• Have working knowledge of numerous lines of business processing guidelines.
• Understand system processing expectations to anticipate adjustment output and identify when adjustments are not processing as intended.
• Interpret instructions from numerous submitters across the Health Plan.

Qualifications:

• High school diploma or equivalent.
• Two years claims processing experience required.
• Ability to use a QWERTY keyboard.
• Knowledge of medical terminology, ICD-9 and CPT coding required.
• Knowledge of commercial, Medicaid, and Medicare products preferred.
• Competency in MS Office and PC skills preferred.
• Ability to demonstrate organizational, interpersonal, and communication skills.
• Ability to prioritize and perform multiple tasks while maintaining designated production and quality standards.

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran