Description
The Claims Quality Support Specialist is responsible for oversight and administration of improved quality outcomes that align with Excellence and Innovation to exceed quality and compliance standards, as well as enhance the customer/member experience for our CHC and TPA teams. This includes data retrieval, trending, analysis and reporting, as well as partnering with Stakeholders to drive operational excellence.
Due to COVID-19 circumstances, this position will temporarily work remotely. This role is eligible for long-term partial work from home privileges, after successful completion of orientation and training (privilege eligibility is subject to continued achievement of business goals and on-site department needs).
Responsibilities:
- Update guidelines on SharePoint for All TPA clients
- Recommend and create training materials to address quality issues
- Design and maintain Quality Standard Dashboards, which include impact analysis, risk assessment, and alignment of process improvement measurements to quality outcomes
- Develop cross-reference guidelines for all processes
- Serve as archivist for stared drive, Gemini, ad SharePoint documentation
- Generates accurate and thorough basic data retrieval to assist with trends and analysis.
- Keeps abreast of all pertinent guidelines, products, regulatory, compliance, policy, and procedures.
- Facilitate Quality meetings with all pertinent Stakeholders to heighten quality awareness and improved quality performance outcomes. This includes meeting documentation and tracking of issue logs.
- Monitor operating performance against Compliance, Service Level Agreement, regional and national benchmarks for quality perspective.
- Successfully manages all assigned projects and initiatives Develop and implement key quality metrics to measure and report on progress of initiatives.
- Monitor, trend, reconcile, and quality review errors and issues leading to member/client/provider dissatisfaction; offering viable solutions to improve processes, procedures, employees tools and training.
- Serve as a quality mentor and resource for team leaders and supervisors;
Qualifications
- Bachelor's Degree or equivalent business experience
- Five years of health insurance operations processing and/or call center/customer service experience with at least two year in a healthcare setting. Competent in claims process operating system.
- Excellent knowledge of medical terminology, ICD-9, ICD-10 and CPT coding required.
- Thorough knowledge of a healthcare benefit plans such as Medicaid, TPA, Medicare, and Commercial products.
- Thorough knowledge of claims processing including Coordination of benefits, adjustments and negative balances.
- Solid documentation, organizational, analytical, interpersonal, and communication skills;
- Competent in Microsoft Office products; Strong working knowledge of Microsoft Access and Excel Preferred;
- A professional demeanor with the ability to manage multiple priorities and meet deadlines;
- Demonstrated ability to lead and/or facilitate meetings;
- Excellent attention to detail;
- Ability to develop and implement key quality metrics to measure and report on progress of initiatives.
Licensure, Certifications, and Clearances:
UPMC is an Equal Opportunity Employer/Disability/Veteran
Total Rewards
More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life &emdash; because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.
Our Values
At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.
