Job Description

Job Title: Operations Analyst, Senior- Claim Operations Compliance
Job ID: 732624
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Operations Support
Location: 600 Grant St, Pittsburgh PA 15219

Description

Oversees administrative, system processes, policies and procedures, and special projects as they relate to implementation and maintenance of the claims transactional system as well as other applications for all UPMC Health Plan products. Under the general direction of the Claims Operations, this role will analyze, identify, propose and implement solutions for all business areas. Acts as subject matter expert supporting all areas, and interacts with staff to answer questions and resolve issues related to policies and procedures as well as claims processing procedures. The Operations Analyst, Senior must use their knowledge and understanding of financial, clinical and other information generated by numerous sources to identify opportunities to improve processes relating to claims adjudication and claims policies and procedures. Furthermore, the position requires the ability to articulate these opportunities to internal and external audiences, implement the solutions, and track and monitor progress. Will take a leadership role in the enhancement, development, documentation, and communication of new and updated policies and procedures. These functions must be done while also weighing the practical considerations and potential barriers that need to be overcome to successfully implement new programs and processes. To successfully perform the role, must understand the causes of processing and systematic error occurrence.


Responsibilities:
  • Actively identifies and implements work process improvements to enhance team performance
  • Administer, identify, test, audit and implement new processes on transactional claims systems
  • Assists other departments during periods of backlogs
  • Attends meetings on behalf of Manager/Director
  • Completes inquiries generated from the data reporting and analysis area
  • Completes Executive Summary management documentation as required
  • Identify appropriate resources and support needed to facilitate decisions to achieve optimal outcomes
  • Identify areas of concern that may compromise client satisfaction through data analysis, and propose solutions based on findings, expertise, and research
  • Interface with customers by telephone, correspondence, and or in person to answer inquiries and resolve concerns/issues
  • Maintain employee/insured confidentiality
  • Maintains and updates MC400 enhancement log and tracking form; documents specifications for system enhancements on appropriate forms retaining data on department share drive; ensures all activities are appropriately monitored and resolved timely
  • Manages special projects as assigned by Management team; develops/maintains project plans, as needed
  • Manages, updates, and maintains source data dictionaries as they relate to processes
  • Meets deadlines and turnaround times set by Management staff which may, at times, require an employee to work extended hours until completion of project
  • Model business requirements for new systems, special projects and enhancements to existing systems; validate and test fixes/enhancements to new and existing systems
  • Openly participate in team meetings, provide ideas and suggestions to ensure client satisfaction, and promote teamwork
  • Participates in training programs when available/as requested
  • Performs in accordance with system-wide competencies/behaviors
  • Performs other duties as assigned
  • Provides support to Operations Analysts
  • Takes a leadership role in mentoring and motivating staff building a strong cohesive team

Qualifications

  • Bachelor's Degree or equivalent work experience 
  • Minimum five years general business experience 
  • Experience in health care insurance or health care industry preferred, but those with relevant experience in other industries will be considered 
  • Knowledge of Commercial, Medicaid, Medicare and Individual products preferred 
  • Competence in MS Office required, including MSExcel, MSAccess, MSWord Excellent planning communication, documentation, analytical and problem solving abilities 
  • Ability to work in a fast-paced environment 
  • Must possess strong interpersonal, organizational, and project management skills, with the ability to work on multiple tasks simultaneously
  • Previous claims experience is preferred
  • Demonstrated ability to work successfully in a project environment is preferred.

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

Salary Range: $24.27 to $41.99

Union Position: No

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.



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.

Share:
Talent Network