Associate II - BPM

Claims Examiner

UST HealthProof is looking for Claims Examiner, reporting to the Claims Team Leader, the Examiner is responsible for adjudication of healthcare claims utilizing employer and payer specific policies and procedures. Responsible for reviewing the data in the claims processing system and compare with corresponding UB04 or CMS1500. Responsible for reviewing claims attachments when necessary to determine if services rendered was medically appropriate and benefit coverage criteria has been met. Responsible for reviewing adjudication software system’s claim and line items edits for determination of whether to pay claim/line item(s).


As a Claims Examiner at UST HealthProof, this is your opportunity to

• Be responsible for attending and successfully completing the trainings scheduled by the client and employer  

• Be responsible for processing assigned claims based on client specified guidelines or as directed by team lead

• Be responsible for meeting claims productivity targets of claims per hour or day as set by team lead

• Collaborate with other team members on special projects as assigned by the team leads including process documentation, training, quality audit, assist with surge activity for client (s), or any other project as determined by the team lead

• Develop Knowledge of physician practice and hospital coding, billing and medical terminology, CPT, HCPCS, ICD-10, UB04, CMS 1500, authorization and other terms, terminology, and concepts of healthcare

• Develop some level of communication with client Claims managers to address issues, concerns and take preventive measures to avoid service quality issues

• Be responsible for your attendance, time off and reporting shift timings etc. with the prime objective of meeting and exceeding customer deliverables

• Participate in meetings and project activities outside of the primary location at locations determined by UST management team and team lead

You bring:

• High School degree required with one year of relevant professional experience in Healthcare claims operations for an insurance company or healthcare payor.

• Willingness to learn new skills and succeed in a new career

• Excellent verbal and written communication skills.

• Proficiency with MS Office applications, especially Word and Excel.

• Team collaborator

• ICD-9 and ICD-10 coding is a plus, CPT and HCPCS coding, HIPAA is a plus

• Strong work ethic with ability to multi-task is essential

• High proficiency in using MS Excel and MS Office Suite

• Good understanding and ability to analyse claims data and report, SLA, KPI, operations report and present findings in a structured way

For this role, we value:

• The ability to adapt quickly to a fast-paced environment, self-starter, and quick learner

• Excellent written and oral communication skills

• Team Player and ability to collaborate

• Perform other duties as assigned.



Overall Experience level: 0-2 years of operation experience, any healthcare


Location: This position will be based in Pittsburgh, PA, USA.

Full time
Pittsburgh, PA 15289, US