Medical Only Claims Specialist I

7 hours ago

Pittsburgh, Pennsylvania, United States UPMC Full time

UPMC WorkPartners is hiring a full-time Medical Only Claims Specialist I to join the Workers Comp Claims team. This role follows a standard Monday through Friday schedule during daylight hours. The position is primarily remote, with occasional in-office presence required—typically once a month—at the U.S. Steel Tower. Candidates should reside locally in the Pittsburgh area

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 claims experience 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:
- Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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