Adjudications Officer

About the Company

UPMC is a $27 billion healthcare provider and insurer, and the largest employer in Pennsylvania. Headquartered in Pittsburgh, UPMC is a world-renowned health system and integrated enterprise with an uncompromising commitment to clinical excellence, research, and service to its communities. With 40 hospitals and more than 800 doctors’ offices and outpatient sites, UPMC is a global leader in healthcare innovation, leading breakthroughs in areas from transplantation to cancer treatment. Our mission is to serve our community by providing outstanding patient care and to shape the future of healthcare through world-class research and education.

Job Description

We are seeking a diligent and detail-oriented Adjudications Officer to join our dynamic team. The Adjudications Officer will be responsible for reviewing, analyzing, and processing complex claims and appeals related to medical services, ensuring compliance with established policies, procedures, and regulatory requirements. This role requires a thorough understanding of healthcare regulations, excellent analytical skills, and a commitment to fair and accurate decision-making. The ideal candidate will possess strong communication skills to articulate decisions clearly and professionally to various stakeholders.

Key Responsibilities

• Review and process medical claims and appeals in accordance with plan benefits, policies, and regulatory guidelines.
• Conduct thorough research and analysis of medical records, documentation, and policy provisions to determine claim eligibility and appropriate resolution.
• Identify, investigate, and resolve discrepancies or complex issues related to claims processing.
• Communicate adjudication decisions clearly and concisely to members, providers, and other relevant parties, both verbally and in writing.
• Maintain accurate and detailed records of all claim activities and decisions in compliance with internal and external standards.
• Collaborate with internal departments such as legal, compliance, and clinical teams to resolve complex cases.
• Stay updated on industry regulations, healthcare policies, and procedural changes impacting claim adjudication.
• Contribute to the continuous improvement of adjudication processes and systems.

Required Skills

• Bachelor's degree in Healthcare Administration, Business, Finance, or related field.
• Minimum of 4 years of experience in claims adjudication, appeals processing, or a similar regulatory compliance role within the healthcare industry.
• In-depth knowledge of medical terminology, coding (ICD-10, CPT, HCPCS), and healthcare reimbursement methodologies.
• Strong analytical and problem-solving skills with meticulous attention to detail.
• Excellent written and verbal communication skills.
• Proficiency in Microsoft Office Suite and claims processing software.
• Ability to work independently and as part of a team in a fast-paced environment.

Preferred Qualifications

• Master's degree or professional certification (e.g., AHIMA, AAPC).
• Experience with UPMC internal systems and policies.
• Familiarity with state and federal healthcare regulations specific to Pennsylvania.
• Demonstrated ability to manage a high volume of complex cases.

Perks & Benefits

• Comprehensive health, dental, and vision insurance plans.
• Generous paid time off and holiday schedule.
• 401(k) retirement plan with company match.
• Tuition reimbursement and professional development opportunities.
• Employee wellness programs and discounts.
• Access to state-of-the-art medical facilities and services.
• Dynamic and supportive work environment.

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