Medical Only Claims Specialist II - Pittsburgh

Pinnacle Health Systems•Pittsburgh, PA

51d•Hybrid

About The Position

UPMC WorkPartners is hiring a full-time Medical Only Claims Specialist II 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 2 reports to the Workers' Compensation Supervisor. This is an intermediate level position within the Workers' Compensation Claims Department. The Medical Only Claims Specialist 2 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 2 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 2 years of administrative, claims, and/or customer service experience, preferably in Workers Compensation.
A minimum of 1 year of Workers Compensation medical only claim handling experience required
Demonstrated verbal and written communications skills.
Demonstrated analytical and decision making skills.
Appropriate state licensing to be secured as needed.
Excellent communication skills.

Responsibilities

Establish appropriate reserves and review on a regular basis to ensure adequacy under supervision as necessary.
Determine validity and compensability of the claim independently.
Manage non-complex and non-problematic medical-only, restricted medical only, and limited lost time claims under some supervision.
Minor negotiations of claims for compromise and release
Investigate the claims through telephone, written correspondence, and/or personal contact with injured workers, insureds, witnesses and others having pertinent information.
Communicate claim status with the injured worker, insured, and broker as needed.
Adhere to client and carrier guidelines and participate in claims review as needed.
Receives claim, confirms policy coverage and acknowledgement of the claim
Establish reserves and authorize payments within authority limits.
Assists other claims professionals with more complex or problematic claims as necessary, which could include periodic handling of litigated cases
Participate in periodic claim reviews as needed.
Appropriate state licensing to be secured as needed.
Mentoring and training new employees as appropriately assigned by management.
Participate in monthly account renewal meetings as needed.