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Job Description

Job Title: Quality Assurance Reviewer II- Government
Job ID: 621106208
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: Quality Assurance
Location: 600 Grant St, Pittsburgh PA 15219


UPMC Health Plan's Quality Assurance Department is seeking a Reviewer II! 

Responsible for quality review of processed claims, including behavioral health claim, checks, adjustments and membership application entry for Health Plan Staff. 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.

Preferred backgrounds would be: Appeals and Grievances, Pharmacy Experience and quality audit/ review experience. 

This position could have the ability to work from home at management's discretion. 

  • Serves as QA Department representative at designated Health Plan meetings as directed by Supervisor.
  • Participate in higher level auditing activities such as high dollar audits.
  • Serve as a process expert for QA tracking and reporting databases.
  • Provide training to new QA Staff as needed.
  • Calculate and prepare statistical data for Claim Entry Staff performance standards.
  • Resolve error appeals on a timely basis.
  • Maintain or exceed designated quality and production goals.
  • Maintain employee/insured confidentiality.
  • Assist in implementing improvement activities, target potential problems.
  • Assess, investigate and resolve difficult issues to ensure customer satisfaction.
  • Participate as needed in special projects and other auditing activities.
  • Provide assistance to other departments as requested.
  • 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.
  • 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.
  • 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.
  • Participate in all relevant training programs to develop a thorough understanding of the materials presented to the claim and service staff.
  • Understand team and individual performance against designated quality standards.
  • Make recommendations regarding development and revision of QA department policies and procedures.


  • High school graduate or equivalent, Bachelor's degree preferred
  • 3-5 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/Disability/Veteran

Salary Range: $17.97 to $29.87 / hour

Union Position: No

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