Job Description

Job Title: QA Analyst, Intermediate
Job ID: 619680
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day
Facility:
Department: Community HealthChoices
Location: 600 Grant St, Us Steel Tower Pittsburgh 15219

Description

Purpose:
UPMC Health Plan is seeking a Quality Assurance Analyst- Intermediate! The Insurance Auditor Intermediate is responsible for the review and reporting of high dollar claims. This auditor also participates in higher level audting actitivies such as focused udits of operational, regulatory and other controls.

 

This is a Monday through Friday, daylight, role in the US Steel Tower. Apply today!

Responsibilities:

  • Assesses, investigates and resolves difficult issues to ensure customer satisfaction.
  • Assists in the development and revision of QA department policies and procedures.
  • Audits high dollar claims on a prospective and/or retrospective basis.
  • Compiles and reports statistical data to internal and external customers.
  • Designs and maintains reports, auditing tools, databases and related documentation.
  • Devises sampling methodology and retrieves audit samples from appropriate sources.
  • Identifies root causes and associated error trends to determine appropriate training needs and suggest modifications to policies and procedures.
  • Leads process improvement activities, target potential problems.
  • Maintains employee/insured confidentiality.
  • Participates in all training programs to develop a thorough understanding of the materials presented to the claim and service staff.
  • Participates in higher level auditing activities such as focused audits of operational, regulatory or other controls.
  • Serve 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 respond to customers' requests.
  • Works with Reimbursement and Configuration Specialists to ensure correct payments and identify/resolve payment inaccuracies.

Qualifications

  • High school and five years of claims processing, experience in physician, ancillary and/or hospital reimbursement delivery systems or insurance reimbursement, including subrogation and overpayment recovery or a Bachelors degree and one year of experience required.
  • Basic understanding of managed care delivery systems.
  • Experience and knowledge of reimbursement mechanisms and clinical/procedural coding or five years of claims processing experience, including commercial and government health insurance plans and other insurance/network products.
  • Excellent analytical skills, familiarity with basic statistical analysis, and proficiency in utilizing PC based applications (i.e. Excel, MS access, COGNOS).
  • 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.
  • ACL or similar software proficiency preferred.

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

Salary Range: $21.94 to $37.97

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!

QUALITY & SAFETY
DIGNITY & RESPECT
CARING & LISTENING
RESPONSIBILITY & INTEGRITY
EXCELLENCE & INNOVATION

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.

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