Job Description

Job Title: Quality Assurance Analyst, Associate
Job ID: 68743247
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 looking for a detail oriented individual with claims processing experience to be their next Quality Assurance Analyst- Associate!

The Insurance Auditor Associate is primarily responsible for the review of high dollar claims and associated reporting.

This role offers flexible work hours as well as work from home opportunities after the initial training period. 

Responsibilities:
  • Maintains employee/insured confidentiality.
  • Understands 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 respond to customers' requests.
  • Audits high dollar claims on a prospective and/or retrospective basis.
  • Works with Reimbursement and Configuration Specialists to ensure correct payments and identify/resolve payment inaccuracies.
  • Assesses, investigates and resolves difficult issues to ensure customer satisfaction.
  • Compiles and reports statistical data to internal and external customers.
  • Participates in all training programs to develop a thorough understanding of the materials presented to the claim and service staff.
  • Leads process improvement activities, target potential problems.
  • Identifies root causes and associated error trends to determine appropriate training needs and suggest modifications to policies and procedures.
  • Devises sampling methodology and retrieves audit samples from appropriate sources.

Qualifications

  • High school and four (4) years of claims processing, experience in physician, ancillary and/or hospital reimbursement delivery systems or insurance reimbursement, including subrogation and overpayment recovery 
  • or a Bachelor's degree required. 
  • Basic understanding of managed care delivery systems. 
  • Experience and knowledge of reimbursement mechanisms and clinical/procedural coding or five years of claims processing experience, including commercial and government health insurance plans and other insurance/network products. 
  • Excellent analytical skills, familiarity with basic statistical analysis, and proficiency in utilizing PC based applications (i.e. Excel, MS access, COGNOS). 
  • Detail-oriented individual with excellent organizational skills. 
  • High level of oral and written communication skills. 
  • Intermediate proficiency with Excel. 
  • Intermediate proficiency with MS Office products.

Licensure, Certifications, and Clearances:

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $21.22 to $36.63 / hour

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.


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