At UPMC, we are committed to keeping our communities safe and healthy as the COVID-19 pandemic continues to evolve. As our recruiters work to fill positions during this time, interviews and recruitment-related processes have been modified to protect and prioritize the safety of our candidates and employees.

UPMC continues to comply with any governmental guidance related to local, state, and federal COVID-19 vaccination and testing requirements where our team members live and work. UPMC strongly supports vaccination and encourages everyone who can get vaccinated to do so to protect themselves, their co-workers, and our patients. At this time, the COVID-19 vaccination is available for new or existing employees on a voluntary basis, except where required by local, state, or federal authorities. Staff in positions in our New York, Maryland, and City of Philadelphia areas must be in compliance with local COVID-19 mandates.

For more information about UPMC’s response to COVID-19, please visit upmc.com/coronavirus.

Search Our Jobs

   Current UPMC employees must apply in HR Direct

Operations Excellence Analyst, Intermediate - Claim Compliance

  • Job ID: 234028529
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: Operations Support
  • Location: Work From Home
  • Union Position: No
  • Salary Range: $25.81 to $44.67 / hour

Description

At UPMC, we’re all here for the same reason – to make Life Changing Medicine happen. Join our team and you will play a unique and important role in our mission to change healthcare for the better.

UPMC Health Plan has an exciting opportunity for a full-time Operations Excellence Analyst (OEA), Intermediate to support the Claim Compliance team within our Operations Support department. This is a Monday – Friday daylight role. This is primarily a remote/work-from-home position, with travel to the office for training purposes.

Under the management of the Sr. Manager of Claims, the Operations Excellence Analyst Intermediate will provide operational and strategic insights to improve the compliance, productivity, and overall performance of the Claims organization. As part of a team of driven, creative, and innovative professionals, the OEA will have the opportunity to influence the strategic direction of the entire Claims organization. From start to finish, the OEA would be responsible for project phases including: research & analytics, building cross-functional, presenting recommendations to Strategy Managers and/or Claims senior and executive leadership.

Experience working with SQL Server, Oracle, and/or Microsoft Access is preferred.
 



Responsibilities:

  • Supports Management in department-related research and projects as requested.
  • Ability to perform complex research and analysis to support business operations.
  • Assist and advise claims adjusters and corporate personnel on Risk Management interpretation of various claims.
  • Develops recommendations to address problems/issues and makes presentations to the supervisor, project leader or manager.
  • Work with existing software and programs to capture, validate, contextualize and share findings.
  • Develop and test new tools, reports and technologies.
  • Ensure daily data capture allows for metrics analysis and operations coordination.
  • Prepare monthly and quarterly status reports, as well as ad hoc loss runs and other claim data analyses from the TPA?s system, company information and other sources.
  • Coordinate the evaluation, direction and management of claims - corresponding directly with departments throughout the UPMC and brokers - with an aim to minimize losses. This will include: Supervising the investigation of claims and suits by coordinating and consulting with adjusters.Advising in the denial or acceptance of all claims. Advise the claims adjusters on legal and insurance issues involving indemnification provisions, subrogation, cross liability issues, and other claim management issues
  • Participate in determining the appropriate configuration of the claims payment process in the appropriate subsystem of the claims payment information system in conjunction with health plan, claims and corporate management and information systems staff
  • Compiles information and analyzes qualitatively and/or quantitatively and conducting follow up and data verification as needed. Analyze feasibility, cost ramifications, economies, or other aspects of large or complex programs. Participates in and may lead the implementation of special projects.

Qualifications

  • Bachelor's Degree and/or equivalent education or work experience
  • 5 years operations health insurance and/or customer service experience required.
  • Strong analytical skills
  • Skilled in reading and writing moderate to complex SQL commands and accurately assessing results (preferable 3+ years).
  • Advanced analytical/problem solving and research skills with proven ability to make data driven decisions; proficient in Excel and PowerPoint with SAS or SQL preferred.
  • Working knowledge of relational databases, database structures.
  • Ability to operate independently: exhibiting independent decision making in a fast paced environment dealing with a high level of ambiguity.
  • Strong time management skills.
  • Excellent documentation, organization, interpersonal, and written communication skills.
  • A professional demeanor with the ability to manage multiple priorities and meet deadlines required.
  • Proficient in SharePoint Designer Software Comprehensive report generation/claim data extraction


Licensure, Certifications, and Clearances:

  • Act 34


    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