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   Current UPMC employees must apply in HR Direct

Quality Assurance Analyst, Intermediate (Remote, PA)

Description

UPMC Health Plan's Quality Assurance Department is seeking a Quality Assurance Analyst- Intermediate!

The Insurance Auditor Intermediate is responsible for the review and reporting of high-dollar claims. This auditor also participates in higher-level auditing activities such as focused audits of operational, regulatory, and other controls. The person who will fill this role must have claims processing experience. 

This is a work-from-home position, ideally in Western, PA. 

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 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.
  • Must have claims processing experience. 
  • 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 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 — 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