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Claims Quality Support Specialist

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 Claims Quality Support Specialist to support the Operations department. This is a Monday – Friday daylight role (7:30 a.m. - 4:00 p.m.) and is based out of Pittsburgh, PA. This is a hybrid role, with some remote/work-from-home privileges, as well as some travel to the office (at the Harbor Gardens location) for trainings, meetings, department needs, etc.

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. This includes data retrieval, trending, analysis and reporting, as well as partnering with Stakeholders to drive operational excellence.


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.
  • 5 years of health insurance operations processing and/or call center/customer service experience with at least 2 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 — 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