Job Description

Job Title: Quality Assurance Reviewer III-Government Products
Job ID: 79074389
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: Quality Assurance
Location: 600 Grant St, Pittsburgh PA 15219



The QA Government Products team works with many lines of business, such as Medicare, Medicaid, CHC, CHIP, Exchange/Marketpace and the ability to learn about each of these types of plans is a great learning opportunity and to enhance career growth.

This role would be responsible for quality review and or internal audit of processed claims, including behavioral health claims, checks, adjustments and work flows. Assists in the development of QA department policies/procedures. Serves as policy and procedure expert for claims auditing functions. Performs higher level auditing functions, including peer review of audits to ensure Health Plan compliance with Government Products. 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.

Will have the ability to work from home several days a week once the candidate has come out of training successfully.

  • 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.
  • Develops and maintains auditing tools.
  • Maintains or exceeds designated quality and production goals.
  • Maintain employee/insured confidentiality.
  • Identifies errors trends to determine appropriate training needs and suggest modifications to policies and procedures.
  • Assists supervisor with research, resolution and response of error appeals.
  • Provides trending, analysis and reporting of auditing data to make recommendations quality improvement.
  • Provide training to new QA staff as needed.
  • Coordinate claims auditing activities for specific teams.
  • Perform peer review of new and or existing QA staff members.
  • Serves as process expert for MC400 claims auditing function.
  • Serves as a QA department representative at designated Health Plan meetings, document and present findings to QA staff.
  • Serves as a backup for the Team Lead.
  • Assists manager and supervisor in the development and revision of QA department policies and procedures
  • Participates as required in special projects and other auditing activities.


  • Bachelor's degree or equivalent education and experience.
  • Five to seven (5-7) years health insurance operations experience required.
  • Keyboard dexterity and accuracy.
  • Ability to maintain designated production standards, multiple projects and tasks.
  • Extensive knowledge of medical terminology, ICD-9 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: $18.79 to $31.23 / hour

Union Position: No

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