Job Description

Job Title: QA Reviewer II-Govt
Job ID: 729272
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 is seeking a QA Reviewer II- Government!

 

This role serves as policy and procedure expert. Interfaces with Claims Staff, Training Department and other functional areas to meet or exceed service requirements. Performs higher level auditing functions including audits to ensure Health Plan compliance with Government Products. Retrieves, and monitors random audit reports. Represents QA dept at QA feedback and Health Plan meetings. Assists in maintaining QA department auditing and training tools. Provides training and assistance to QA staff.

Responsibilities:
• Assess, investigate and resolve difficult issues to ensure customer satisfaction.
• Assist in implementing improvement activities, target potential problems.
• Calculate and prepare statistical data for Claim Entry Staff performance standards.
• Compile and report statistical data to internal and external customers.
• 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.
• Make recommendations regarding development and revision of QA department policies and procedures.
• 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.
• Participate in higher level auditing activities such as high dollar audits.
• 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.
• Provide training to new QA Staff as needed.
• Resolve error appeals on a timely basis.
• Serve as a process expert for QA tracking and reporting databases.
• Serves as QA Department representative at designated Health Plan meetings as directed by Supervisor.
• 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.

Qualifications

  • High school graduate or equivalent
  • Bachelors degree preferred.
  • Three-Five years health insurance operations required.
  • 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.

    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

Apply Current Employee?

UPMC VALUES

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.


WORKING HERE



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.

Learn more about working here and check out our policies and recent updates.


UPMC Ranked #17 Best Places for Women & Diverse Managers in 2018

Share:
Talent Network