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Staff Development Specialist

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UPMC

19d ago

  • Job
    Full-time
    Junior Level
  • People, HR & Administration
    Healthcare
  • Erie

AI generated summary

  • You need a high school diploma, 2 years of claims/call center experience (1 year in healthcare), knowledge of claims processes, medical terminology, and MS Office skills.
  • You will analyze projects, trend provider issues, ensure quality customer service, coordinate training, support cross-functional teams, communicate with providers, and mentor team members.

Requirements

  • High school graduate or equivalent, college degree preferred.
  • 2 years of claims processing and/or call center experience with at least 1 year in a healthcare setting.
  • Competent in claims process operating system.
  • Excellent knowledge of UPMC's Health Plan internal department functions.
  • Excellent knowledge of medical terminology, ICD-9, ICD-10 and CPT coding required.
  • Thorough knowledge of a minimum of two cross-functional areas, including but not limited to Commercial, Medicare, Medicaid, Evolent, Ancillary, and/or claims processing.
  • Thorough knowledge of claims processing including adjustments and negative balances.
  • Thorough knowledge of MS Office and PC skills required; Able to demonstrate organizational, analytical, interpersonal, and communication skills; Ability to prioritize and perform multiple tasks while maintaining designated production and quality standards.

Responsibilities

  • Analyze and summarize special projects utilizing Microsoft Excel.
  • Trend provider issues, recognize and identify issues that could substantially negatively impact UPMC Health Plan, its participating providers, and members.
  • Quality customer service includes but is not limited to, responding to customer requests and inquiries in a timely and accurate manner in keeping with Health Plan Policies and Procedures, Department of Public Welfare (DPW) laws and standards, Department of Insurance (DOI) laws and standards, Department of Health (DOH) laws and standards, Department of Health and Human Services (DHHS), Health Care Financing Administration (HCFA), and National Committee for Quality Assurance (NCQA) standards.
  • Identify and report any training issues to other departments during periods of backlog, including but not limited to, claims processing.
  • Actively pursue open cut log inquiries and resolve them within the designated time standards.
  • Support cross-functional team members to meet or exceed designated production and quality standards.
  • Quality customer service should be applied to all customers, including all Health Plan members and potential members, all Health Plan providers and potential providers, all Health Plan and Health System employees, all Health Plan and Health System vendors, and all government and other oversight organization staff.
  • Coordinate, perform, and monitor provider outreach as designated by management.
  • Quality customer service will be measured by, but not limited to, the number of complaints from a customer (with a goal of zero) and by the number of second requests for information or response received (with a goal of zero).
  • Develop and maintain department reference materials.
  • Complete adjustments or other inquiries that are generated from the data reporting and analysis areas.
  • Respond to web messages and claim adjustment requests within time guidelines.
  • Identify individual and department training needs and develop and present training as needed.
  • Provide communication to team members related to processing and procedure changes.
  • Communicate with providers as necessary to problem solve.
  • Escalate issues and concerns in a timely fashion.
  • Communicate with other departments to resolve issues.
  • Support call center when necessary. Must maintain or exceed production and quality standards for service level and/or claims processing. Call quality: 99% production 65 calls per day. Claims quality and production based on department production and quality standards.
  • Act as a mentor to new team members as well as existing staff.
  • Take escalated calls and perform appropriate research and follow-up.
  • Interface with other departments and identify adjustments required as a result of updated provider files, benefits, or eligibility information.
  • Recommend solutions to existing issues. Actively participate in departmental meetings, and offer suggestions and resolutions related to current issues. Performs in accordance with system-wide competencies/behaviors.

FAQs

What is the job title of the position?

The job title is Staff Development Specialist, Provider Services.

What are the primary responsibilities of the Staff Development Specialist?

The primary responsibilities include developing and training staff on eligibility levels, claim interpretation, maintaining reference materials, identifying trends to improve customer satisfaction, and mentoring new staff.

What is the work structure for this position?

This position has a hybrid work structure, working Monday through Friday.

What qualifications are required for this position?

Candidates should have a high school diploma or equivalent (college degree preferred), 2 years of claims processing and/or call center experience (with at least 1 year in a healthcare setting), and a thorough knowledge of medical terminology and claims processing.

Is prior experience in healthcare necessary for this role?

Yes, at least 1 year of experience in a healthcare setting is required.

What software skills are needed for the Staff Development Specialist position?

Candidates must have thorough knowledge of MS Office and PC skills, as well as proficiency in a claims process operating system.

Will the Staff Development Specialist interact with other departments?

Yes, the specialist will communicate with other departments to resolve issues and provide support.

What are the performance metrics for quality customer service?

Quality customer service will be measured by the number of complaints from customers (with a goal of zero) and the number of second requests for information or response received (with a goal of zero).

Is there a mentoring component in this job?

Yes, the Staff Development Specialist will act as a mentor to new and existing staff members.

What areas of knowledge or expertise are emphasized for this role?

Knowledge of UPMC's Health Plan internal department functions, medical terminology, ICD-9, ICD-10 and CPT coding, and claims processing are emphasized for this position.

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UPMC

Life Changing Medicine.

Science & Healthcare
Industry
10,001+
Employees

Mission & Purpose

A $23 billion health care provider and insurer, Pittsburgh-based UPMC is inventing new models of patient-centered, cost-effective, accountable care. The largest nongovernmental employer in Pennsylvania, UPMC integrates 92,000 employees, 40 hospitals, 700 doctors’ offices and outpatient sites, and a 4 million-member Insurance Services Division, the largest medical insurer in western Pennsylvania. In the most recent fiscal year, UPMC contributed $1.4 billion in benefits to its communities, including more care to the region’s most vulnerable citizens than any other health care institution, and paid more than $800 million in federal, state, and local taxes. Working in close collaboration with the University of Pittsburgh Schools of the Health Sciences, UPMC shares its clinical, managerial, and technological skills worldwide through its innovation and commercialization arm, UPMC Enterprises, and through UPMC International. U.S. News & World Report consistently ranks UPMC Presbyterian Shadyside among the nation’s best hospitals in many specialties and ranks UPMC Children’s Hospital of Pittsburgh on its Honor Roll of America’s Best Children’s Hospitals.