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   Current UPMC employees must apply in HR Direct

Quality Assurance Analyst, Intermediate

Description

Purpose:
Shape the world of health care by joining UPMC! As a leader in the industry, we are committed to enhancing the lives of all who are a part of our community. Without our employees, we would not be able to innovate health care for our patients and health plan members. From hospitals to our corporate office, all UPMC employees impact our mission of creating life changing medicine. To continue our tradition of excellence, we are in search for a Quality Assurance Analyst- Intermediate to join this community as well.

The Insurance Auditor Intermediate is responsible for the review and reporting of high dollar claims. This auditor also participates in higher level audting actitivies such as focused audits of operational, regulatory and other controls.

This is a work-from-home position. 

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 five (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  one (1) year of experience required.
  • Basic understanding of managed care delivery systems.
  • Focused audit / or Quality Assurance experience
  • Intermediate analytical skills, familiarity with complex statistical analysis, and proficiency in utilizing PC based applications (i.e. Excel, MS access, COGNOS).
  • Strong subject matter expertise and knowledge of Commercial laws, regulations, contractual requirements, industry standards and best practices preferred.
  • Strong acumen and understanding of healthcare, health insurance and managed health care industries and organizations required. 
  • 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 or similar software proficiency preferred.

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.

   Current UPMC employees must apply in HR Direct

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