Job Description

Job Title: QA Analyst, Intermediate (Commercial Compliance & Regulatory Review)
Job ID: 71047423
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 Department is immediately seeking a QA Analyst, Intermediate!

This specific team handles commercial compliance and regulatory requirements. The Insurance Auditor Intermediate is responsible for the review and reporting of high dollar claims. This auditor also participates in higher level auditing activities such as focused audits of operational, regulatory and other controls.

This role is eligible for work-from-home at the Senior Manager's discretion.

Responsibilities:
  • Designs and maintains reports, auditing tools, databases and related documentation.
  • Maintains employee/insured confidentiality.
  • Participates in higher level auditing activities such as focused audits of operational, regulatory or other controls.
  • Devises sampling methodology and retrieves audit samples from appropriate sources.
  • Assists in the development and revision of QA department policies and procedures.
  • Compiles and reports statistical data to internal and external customers.
  • Assesses, investigates and resolves difficult issues to ensure customer satisfaction.
  • Identifies root causes and associated error trends to determine appropriate training needs and suggest modifications to policies and procedures.
  • Serve as a QA Department representative at internal and external meetings, document and present findings to QA Staff.
  • Participates in all training programs to develop a thorough understanding of the materials presented to the claim and service staff.
  • Audits high dollar claims on a prospective and/or retrospective basis.
  • Leads process improvement activities, target potential problems.
  • 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.
  • Works with Reimbursement and Configuration Specialists to ensure correct payments and identify/resolve payment inaccuracies.

Qualifications

  • High school and 5 years of claims processing, experience in physician, ancillary and/or hospital reimbursement delivery systems or insurance reimbursement, including subrogation and over payment recovery 
  • or a Bachelor's degree and one year of experience required
  • Experience conducting relevant operations compliance reviews – preferred
  • Minimum of 3 years healthcare operations, commercial quality assurance and/or regulatory compliance experience – preferred
  • Prior in-house (UPMC or other healthcare company) compliance experience strongly preferred
    • Experience conducting relevant operations compliance reviews – preferred
    • Subject matter expertise and knowledge of commercial healthcare laws, regulations, contractual requirements, industry standards and best practices – preferred
    • Strong understanding of health care operations, health insurance and managed health care industry.
    • Excellent oral, listening and written communication skills
    • Strong analytical and organization skills as well as problem solving capabilities
    • Strong partnership, relationship and coalition building skills – required
    • Consultative and partnership-oriented approach and experience – required
    • Reliable judgement and discretion required with strong ability to work independently to identify and navigate commercial compliance-related issues.


Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

Salary Range: $23.75 to $41.09 / 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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