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Job Description

Job Title: Quality Assurance Reviewer II-Claims
Job ID: 899052526
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 Quality Assurance Reviewer II. 

This role is responsible for quality review of processed claims, including behavioral health claim, checks, adjustments, CCBH check reviews, special projects and membership application entry for Health Plan Staff. Interfaces with Claims Staff, Training Department and other functional areas to meet or exceed service requirements. Completes peer review of audited claims and auditing to ensure Health Plan compliance with all lines of business. Provides trending, analysis, and reporting of auditing data to make recommendations for quality improvement.

It is very important to have health care claims experience to be considered for this role. Also, experience in adjusting and processing claims with secondary coverage plans.

This is a work from home position.

  • Identify error trends to determine appropriate training needs and suggest modifications to policies and procedures.
  • Maintain employee/insured confidentiality.
  • 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.
  • Participate as needed in special projects and other auditing activities.
  • Maintain or exceed designated quality and production goals.
  • Provide assistance to other departments as requested.
  • 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.
  • Understand team and individual performance against designated quality standards.
  • Participate in all relevant training programs to develop a thorough understanding of the materials presented to the claim and service staff.
  • Assess, investigate and resolve difficult issues to ensure customer satisfaction.


  • High school graduate or equivalent, 
  • Bachelor's degree preferred. 
  • 3-5 years of claims processing; health insurance audit, or analysis experience required. 
  • Keyboard dexterity and accuracy. 
  • Ability to maintain designated production standards. 
  • Knowledge of medical terminology, ICD-9 and CPT-4 coding. 
  • Knowledge of HMO, POS and PPO plans. 
  • 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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