Medical Only Claims Specialist I - Pittsburgh

UPMC • Pittsburgh, PA

2d • Hybrid

About The Position

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.

Requirements

• 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.

Nice To Haves

• Prior claims experience strongly preferred.

Responsibilities

• Manage non-complex and non-problematic medical-only and restricted medical only, claims under close supervision.
• Additional duties as required.
• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Number of Employees: 5,001-10,000 employees