Job Description

Job Title: Quality Assurance Reviewer III-Claims
Job ID: 686602
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.

Ability to maintain designated production standards, multiple projects and tasks. Team Lead experience would be helpful.


This department allows eventual work-from-home.


  • Assists manager and supervisor in the development and revision of QA department policies and procedures.
  • Assists supervisor with research, resolution and response of error appeals.
  • Develops and maintains auditing tools.
  • Identifies errors trends to determine appropriate training needs and suggest modifications to policies and procedures.
  • Maintain employee/insured confidentiality.
  • Maintains or exceeds designated quality and production goals.
  • Participates as required 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.
  • Performs quality review on all types of claims, including behavior health claims, adjustments, checks and workflows using root cause analysis in accordance with company policies and procedures.
  • Provides training to new QA Staff as needed.
  • Provides trending, analysis and reporting of auditing data to make recommendations quality improvement.
  • Serves as a QA department representative at designated Health Plan meetings as directed by supervisor.
  • Serves as process expert for MC400 claims auditing function.


  • Bachelors degree or equivalent education and experience.
  • 5-7 years of claims auditing experience required
  • Keyboard dexterity and accuracy.
  • Ability to maintain designated production standards, multiple projects and tasks. Extensive knowledge of medical terminology, ICD-10 and CPT-4 coding. Extensive knowledge of HMO, POS and PPO plans.
  • Extensive knowledge of coordination of benefits, subrogation, Medicare and Medicaid. Detail oriented individual with excellent organizational skills.
  • High degree of oral and written communication skills.
  • Intermediate proficiency with MS Office products and extensive PC skills.

    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: $18.24 to $30.32

Union Position: No

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