Description
Purpose:UPMC Health Plan's Quality Assurance team is seeking a Quality Assurance Reviewer II- Claims!
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.
This role is work-from-home and will need to come onsite for mandatory meetings.
Responsibilities:
Responsibilities:
- 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.
Qualifications
- High school graduate or equivalent, Bachelor's degree preferred.
- Three to five (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
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.
