Job Description

Job Title: Senior Manager, Quality Assurance and Operational Integrity- Technical Team
Job ID: 703165
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:
UPMC Health Plan's Quality Assurance/ Operational Integrity Department is seeking a full time Senior Manager for its Technical team!

 

This professional is responsible for the management of day-to-day activities performed by the Quality Assurance & Operational Integrity (QA) Technical Support Team. The manager provides analytical, data management, and reporting expertise to the QA Technical Support Team, including the design, creation and maintenance of department auditing tools, insurance division audit and compliance data reports, databases and related documentation. This professional acts as liaison with Health Plan operational and IT departments for all lines of business, including commercial, Medicare, Medicaid, and ancillary. This manager will partner with Product management, Organizational Performance and Compliance teams to support routine monitoring, as well as audit readiness efforts.

Responsibilities:

  • Act as a liaison with IT department to support the creation and maintenance of departmental data systems.
  • Acts as a liaison between Health Plan operations and IT departments for all lines of business, including Medicare, Medicaid, and Ancillary departments.
  • Assess, investigate and resolve difficult issues to ensure customer satisfaction. Compile and report statistical data to internal and external customers. Participate as needed in special projects and other auditing or monitoring activities. Serve as a process expert for all QA monitoring and reporting technical tools.
  • Create and maintain department auditing tools
  • Design and maintain databases, reports, auditing tools and related documentation.
  • Devise sampling methodology and retrieve audit samples from appropriate data sources.
  • Identify error trends to determine appropriate training needs and suggest modifications to policies and procedures.
  • Monitor and enforce staff production and quality to meet departmental standards and timelines. Provide leadership to Technical Team staff and serve as a role model by providing quality services and that are responsive to client needs and proactive in scope.
  • Oversee the implementation and maintenance of QA databases, department intranet site, and other software tools.
  • Participate in all training programs to develop a thorough understanding of the materials presented to the claim and service staff. Develop compliance data reports, databases, Insurance Services Division audits and all related documentation.
  • Provide technical assistance to other departments as requested. Completes performance evaluations and coaches/mentors staff. Contributes to defining department�s long-term strategy and goals. Facilitates successful completion of tasks and initiatives by embracing a team-first approach. Works in collaboration with multiple teams and offers feedback and suggestions for process improvement as appropriate. Identify, create and apply process improvement to increase production and service quality to achieve business goals
  • Understand customers including internal Health Plan Departments and external customers, and respond to customers' requests in a timely fashion.

Qualifications

  • Bachelors Degree in job related field
  • Seven years technical work experience, including design and maintenance of databases is required.
  • Seven years of medical claims or health care data mining and reporting experience preferred
  • Five years of supervisory or leadership experience preferred
  • Detail oriented individual with excellent organizational and technical skills.
  • High level of oral and written communication skills.
  • Proficiency with MS Office products, including SQL, Excel and Access.
  • Ability to utilize a corporate data warehouse to design and compile reports. Intermediate understanding of data structures and reporting tools.
  • Ability to create and maintain databases of significant size and complexity.
  • Advanced proficiency in Word, Access, Excel, Power point and Visio.
  • Knowledge of Medicare, Medicaid and Commercial product regulations and related internal controls and processes.
  • Knowledge of medical terminology, ICD-9 and CPT-4 coding preferred.
  • Knowledge of health insurance HMO, POS and PPO plan operations preferred.
  • Experience in a continuous improvement environment with a track record of achieving significant and continual development.

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

Salary Range: $30.89 to $52.76

Union Position: No

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