UPMC Community Care Behavioral Health is hiring a full-time Provider Reimbursement Adjustment Coordinator to support the Provider Reimbursement team. Upon completion of the in-person training period, this role may work predominantly remotely. This role will work Monday – Friday daylight hours.

This is a phone-based role so candidates must be comfortable spending the majority of the day on the phone. 

Under the direction of the Claims Director of Community Care, the incumbent will be responsible for overseeing the processing of all claims by the claims processing vendor.

Responsibilities:

Request system reports to facilitate resolution of assigned provider’s claims issues. Advise the senior claims staff of any irregularities in physician or provider billing procedures. Work with the Director to develop and provide provider claims training. Responsible for understanding and performing job responsibilities consistent with the company’s mission statement, values statement, code of conduct and global goals. Interface with TPA to facilitate and expedite claims payment including question resolution, benefit interpretation and authorization. Schedule review meetings with providers to discuss issues or represent Claims at such meetings as requested by other departments. Quality control functions including accuracy review and efficiency of the claims vendor’s processing of claims and the development of action plans for problem resolution. Ensure that batch integrity is maintained. Provide weekly updates on all assigned providers to senior claims staff. Must be able to travel to provider sites or regional offices Develop spreadsheets to be sent to TPA to correct claims. Follow-up on claims with Provider Relations Department including claims checks, technical questions, or adjustment requests. Responsible for monitoring of assigned providers. Screen, evaluate, edit and correct claims for service under HealthChoices Southwest program and determine eligibility for payment.