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AVP, Quality Assurance & Operational Integrity

Description

The Associate Vice President (AVP), Quality Assurance & Operational Integrity reports to the Senior Vice President, Chief Risk, Compliance & Ethics Officer of UPMC Insurance Services and strategically and operationally leads various quality reviews of claims, Hierarchical Condition Categories (HCC) and clinical coding, call monitoring, system technology upgrades, and other compliance/financial/operational controls and processes across all Insurance Services and Health Plan product lines.

These responsibilities include planning, executing, and evaluating results of audits/reviews and operational integrity initiatives, evaluating error patterns and trends, and ensuring the reporting of relevant audit/review results, pre-payment and post-payment claim reviews, and evaluation of HCC audits/reviews, among others, to relevant departments. The role also leads the organization's Focused Review & Internal Controls; SOX/MAR (Model Audit Rule) testing/assurance; Technology Assurance; and audit management, support and facilitation teams.

This position oversees the Quality Assurance & Operational Integrity department and staff, and directs the activities of the Senior Director, Quality Assurance & Operational Integrity. The AVP, Quality Assurance & Operational Integrity evaluates statistical patterns and trends of quality assurance results and collaborates with owners of audited business areas to address root causation of errors and facilitate overall quality improvement. The leader oversees special projects as identified by executive management, including but not limited to special regulatory reviews, operational/compliance control assessments, financial internal controls, and other such process- and control-improvement matters.

Responsibilities:

  • Develops, assesses, and adapts clear and effective Quality Assurance monitoring, audits/reviews, testing, reporting, and audit sampling methodologies to ensure proper, effective and timely assessments. Conducts regular assessments of existing audit reports, develops new reports as necessary, and facilitates effective remediation of findings and corrective actions. Updates and ensures protocols and controls are followed, including timely completion of audits. Keeps abreast of changing industry requirements, compliance responsibilities, and regulations, including all relevant laws, rules, contractual agreements, industry standards, company practices and initiatives. Provides clear and effective reports to the relevant business, functional and operational areas, as well as other internal/external stakeholders, regarding audit findings, contractual requirements, industry standards and best practices.
  • Conducts regular and ongoing risk-based evaluation of new audit/review opportunities, and conducts regular evaluation of the methodology and relevance of existing audits. Oversees and directs regular gap analyses, risk assessments and program effectiveness assessments for the different Quality Assurance & Operational Integrity programs and functions.
  • Establishes and ensures quality standards by designing effective audits/reviews and selecting the most appropriate and effective sampling methodology to test quality on audited samples.
  • Ensures strategic and operational partnership and collaboration with the business and operational areas, as well as with sibling Governance, Risk & Compliance (GRC) teams to leverage cross-departmental synergy and efficiencies. Develops, chairs, and leads Quality Assurance & Operational Integrity committees and working groups, ensuring that all relevant issues and data are appropriately and timely communicated, understood, aligned upon, and actioned. Owns and performs strategic planning, goal planning, budget planning and management, performance review, professional development, and all other executive-level managerial functions for all Quality Assurance & Operational Integrity Programs, functions, and teams.
  • Develops processes for identifying emerging trends through data gathering and analysis, including industry relevant AI, machine learning, data analytics, scripting, and other such automated tools, and for designing appropriate methods and tools for visual representation of analyzed data to identify trends, patterns, and results to enable effective Board and executive leadership communication and reporting.
  • Ensure maximum productivity on all audits/reviews, which provide management and leadership with timely, effective, and valuable feedback. Analyze, evaluate, and present information concerning relevant factors, such as business scenarios, production capabilities, and design and development of department workflows. Maintain databases, dashboards, scorecards and reports of production, statistical, operational and financial results.
  • Responsible for advanced technical research as it relates to audit/review planning, and compliance with current regulatory and financial reporting requirements. Full ownership and accountability for all Quality Assurance & Operational Integrity programs, activities and reviews, including claims reviews; call center and digital communications reviews; clinical and coding reviews; technology upgrade reviews; Commercial and Government Program product compliance reviews; focused review and internal controls testing and assurance; SOX/MAR testing and assurance; audit management and facilitation; and technology and data analytics implementation and utilization, among other department activities.
  • Inform and advise SVP, Chief Risk, Compliance & Ethics Officer of current trends, issues, problems, and activities in functional areas, and develop and implement appropriate interventions to facilitate problem resolution and policy making. Identify critical business objectives, and develop and operationalize business plans to support critical objectives.
  • Represent the Quality Assurance & Operational Integrity Department to internal and external customers and stakeholders, including regulatory agencies, to build and maintain positive relationships supporting business goals and objectives.
  • Perform other duties as assigned. Effectively live, role model, communicate, and support the values of UPMC and UPMC Health Plan. Effectively build partnerships, working relationships, consensus, and coalitions with all business, operational, functional, internal and external constituents. Perform in accordance with UPMC System-wide competencies and behaviors.
  • Excellent partnership-, working relationship-, consensus- and coalition-building skills to foster and maintain highly effective relationships throughout the organization. Excellent communication and influencing skills, both direct and indirect. Strong consultative and partnership approach that strikes the optimal balance between meeting regulatory and risk management requirements, and understanding and supporting the broader macro industry, strategic, business and operational needs.
  • Strategic thought leader with continuous innovation/improvement mindset and approach. Ability to interact and consult with executive leadership and potentially the Board to achieve and communicate department and program goals, activities and results. Ability to independently develop goals, action plans and contingency plans; identify resource requirements; marshal and organize resources; establish and communicate expectations; and manage multiple tasks simultaneously.
  • Ability to effectively navigate through ambiguity and uncertainty by strategically developing a strong vision and action plan. Ability to act independently and self-sufficiently with minimal supervision or direction.
  • Open, communicative, transparent, collaborative, and action-oriented leader who builds high-performing teams and department cultures and who continuously fosters strong relationships and partnerships across the enterprise. Strong integrity capital with commitment to doing the right thing and upholding organizational values.

Qualifications

  • Bachelor's Degree in Business Administration, Accounting, Finance or related/relevant field required.
  • MBA, MA, JD and/or other advanced degree preferred.
  • CPA and/or CIA certifications preferred.
  • 12+ years of audit (internal and/or external), quality assurance/review, internal controls and assurance, risk management, corporate governance, compliance and/or related experience required, with heavy preference for highly substantive audit, assurance and internal controls experience.
  • Strong preference for extensive healthcare, health insurance and managed care experience, including fully diversified commercial, government programs and behavioral health areas.
  • 6+ years of substantive management and leadership experience required. Knowledge of and/or experience with regulatory and operational requirements for the delivery of health insurance products and services, including Medicare, Medicaid, SNP, CHIP, managed care, Exchange, behavioral health and commercial, as well as the associated and relevant federal, state and local regulatory entities.
  • Knowledge of health insurance information systems, functions and continuous monitoring software to be used as tools for effectively meeting QA objectives is strongly preferred.
  • Direct experience with NCQA accreditation for managed care organizations preferred.


Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct

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