Job Description

Job Title: QA Reviewer II-Claims
Job ID: 672951
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: Quality Assurance
Location: 600 Grant St, Pittsburgh PA 15219



UPMC Health Plan's Quality Assurance Department is seeking a Quality Assurance Reviewer III- Claims!

Responsible for quality review and or internal audit of processed claims, including behavioral health claims and work flows. Performs higher level auditing functions, including peer review of audited claims and auditing to ensure Health Plan compliance for all lines of business. Assists in the development of QA department policies/procedures. Serves as policy and procedure expert for claims auditing functions. Retrieves, distributes and monitors random audit reports. Maintains QA department auditing and training tools. Provides training and assistance to QA staff. Interfaces with internal and external customers to meet or exceed service requirements and requests. Represents QA department at internal and external Health Plan meetings. Provides trending, analysis and reporting of auditing data to make recommendations for quality improvement.



  • 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: $17.11 to $28.43

Union Position: No

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