Job Description

Job Title: QA Reviewer II-Claims
Job ID: 606120
Status: Full-Time
Regular/Temporary: Regular
Shift: Day
Department: Community HealthChoices
Location: 600 Grant St, Pittsburgh PA 15219


UPMC Health Plan is hiring a Quality Assurance Reviewer II - Claims to support the Third Party Administrator Claims Department. In this role, you will be responsible for quality review of processed claims, including behavioral health claim, checks, adjustments, Community Care Behavioral Health (CCBH) check reviews, special projects and membership application entry for Health Plan Staff. You will interface with claims staff, training departments and other functional areas to meet or exceed service requirements. You will complete peer review of audited claims and auditing to ensure Health Plan compliance with all lines of business. You will also provide trending, analysis, and reporting of auditing data to make recommendations for quality improvement.

*Eventual occasional work from home will be an option.
  • Assess, investigate and resolve difficult issues to ensure customer satisfaction.
  • Identify error trends to determine appropriate training needs and suggest modifications to policies and procedures.
  • Maintain employee/insured confidentiality.
  • Maintain or exceed designated quality and production goals.
  • Participate as needed in special projects and other auditing activities.
  • Participate in all relevant training programs to develop a thorough understanding of the materials presented to the claim and service staff.
  • Perform quality review on all types of claims, including behavioral health claims, adjustments and membership applications using root cause analysis in accordance with company policies and procedures.
  • Provide assistance to other departments as requested.
  • Understand customers including internal Health Plan Departments (i.e. claims staff, customer service, Marketing, etc.) and external customers (i.e. Health System Internal Audit, Client Audit teams) and is responsive to customers' requests.
  • Understand team and individual performance against designated quality standards.


  • High school graduate or equivalent, Bachelors degree preferred.
  • Three to Five years data entry.
  • Keyboard dexterity and accuracy.
  • Ability to maintain designated production standards.
  • Working knowledge of medical terminology, ICD-9 and CPT-4 coding.
  • Working knowledge of HMO, POS and PPO plans.
  • Working knowledge of coordination of benefits, subrogation, Medicare and Medicaid.
  • Detail oriented individual with excellent organizational skills High degree of oral and written communication skills.
  • Proficiency in MS Office/PC skills.
  •  Three to five years of health insurance operations, specifically healthcare claims processing and or general auditing experience preferred.

    Licensure, Certifications, and Clearances:
    HIA Health Insurance Associate preferred. MCP Managed Care Professional preferred. CQA Certified Quality Auditors preferred.

    UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $16.61 to $27.60

Union Position: No

At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!


UPMC provides a total rewards package that can help you achieve the goals you have for your career and your personal life. Whether you want to learn a new skill through a training course, reach personal health and wellness targets, become more involved in your community, or follow a career path that provides you with the right experience to be successful, UPMC can help you get to where you want to be.

Now more than ever, YOU can help us shape our communities and UPMC into a better place for everyone to work, study, play, and thrive.

Learn more about working here and check out our policies and recent updates.

Talent Network