Job Description

Job Title: Manager, Quality Assurance and Operational Integrity- Claims
Job ID: 693574
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Quality Assurance
Location: 600 Grant St, Pittsburgh PA 15219

Description

Purpose:
Responsible for daily management of the quality review of claims. Serves as policy and procedure expert. Interfaces with internal and external customers to meet or exceed service requirements and requests. Represents QA department at internal and external Health Plan meetings. Supervises Claims Audit staff. Provides trending, analysis, and reporting of audit data. Collaborates in the analysis and determination of process improvement and the creation and revision of QA department policies and procedures.

 

This role would help support TPA Claims. This roll will be managing inventory, managing staff, performance evaluations, helping to find ways more efficient. Prefers someone who has experience managing staff while managing a workload. This person will also have responsibilities in recruitment and staffing the team. This person will also support Senior Manager and assist with special projects.

Responsibilities:

  • Acts as a liaison between QA and other Health Plan departments.
  • Assesses, investigates, and resolves difficult issues to ensure customer satisfaction.
  • Assists in the development and revision of QA department policies and procedures.
  • Devises sampling methodology and retrieves audit samples from appropriate sources.
  • Identifies error trends to determine appropriate training needs and suggest modifications to policies and procedures.
  • Leads process improvement activities to target potential problems.
  • Maintains audit reports to monitor weekly inventory
  • Maintains employee/insured confidentiality.
  • Maintains staff personnel records and performs staff evaluations.
  • Manages Claim Audit staff.
  • Manages team inventory and workflow.
  • Monitors staff production and quality to meet departmental standards and timelines.
  • Oversees and monitors the random audit activity statistics and reports to departments at required intervals.
  • Oversees benefit, claims, membership, dental, vision and other specific audits.
  • Oversees the design and maintenance of reports, auditing tools, and related documentation.
  • Participates as needed in special projects and other auditing activities.
  • Participates in all training programs to develop a thorough understanding of the materials presented to the claim and service staff.
  • Perform other activities related to the Claim/Non-Claim Audit processes including: Overseeing planning for special projects and training. Overseeing documentation of internal audit processes and associated workflows. Overseeing the development of and revision of audit policies & procedures. Overseeing the development of audit methodologies. Overseeing the development and maintenance of audit tools.
  • Provides assistance to other departments as requested.
  • Provides direction to the QA Team Lead.
  • Serve as a role model by providing quality services that are responsive to client needs and proactive in scope.
  • Serves as a QA Department representative at internal and external meetings; document and present findings to QA Staff.
  • Understands 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 responds to customers' requests.

Qualifications

  • Bachelors degree required.
  • Five (5) years of combined insuarance claims processing and or insurance auditing experience required.
  • five (5) years of supervisory experience required.
  • Ability to maintain designated production standards, multiple projects, and tasks.
  • Knowledge of medical insurance for all lines of business, including commercial and government products.
  • Knowledge of coordination of benefits, subrogation, and other overpayment recovery efforts.
  • Detail-oriented individual with excellent organizational skills
  • High level of oral and written communication skills Advanced proficiency with Excel. Intermediate to advanced proficiency with MS Office products and extensive PC skills

    Licensure, Certifications, and Clearances:
    UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $28.37 to $47.88

Union Position: No

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