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Job Description

Job Title: Quality Assurance Analyst, Intermediate- Overpayment/Recovery
Job ID: 845130328
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:
The Quality Assurance & Operational Integrity (QAOI) Analyst Intermediate is responsible for the administration of the vendor overpayment recovery process. This analyst also participates in higher level review activities including root cause analysis, reporting and tracking.

This role is work-from-home and offers a flexible schedule. 

Responsibilities:
    • Designs and maintains reports, process flows, databases and related documentation.
    • Maintains employee/insured confidentiality.
    • Participates in higher level review activities such as root cause analysis, financial reporting and tracking.
    • Tracks claim files to and from vendors.
    • Assists in the development and revision of QA/OI 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 and tracks error trends to determine appropriate training needs.
    • Serve as a QA Department representative at internal and external meetings, documents and present findings to QA Staff as needed.
    • Participates in all training programs to develop a thorough understanding of the materials presented to the claim and service staff.
    • Reprices claims and facilitates associated adjustments within specified time frames.
    • Leads process improvement activities, targeting 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, Vendor) and responds to customers' requests.
    • Works with Operations departments 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 overpayment recovery or a Bachelor's degree and 1 year of experience 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. 
  • Advanced proficiency with Excel. 
  • Intermediate to advanced proficiency with MS Office products and extensive PC skills. ACL. SQL or similar software proficiency preferred. 
  • Excellent time management skills.

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

Salary Range: $23.75 to $41.09 / hour

Union Position: No

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