COVID-19 Vaccination Information

Across UPMC, our guiding principle is to always prioritize the safety of our employees, patients, and members. UPMC believes that vaccination is important, helps protect all, and advocates that everyone who can be vaccinated should be vaccinated.

UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

If you are not yet vaccinated, we urge you to get a vaccine now. You can schedule your COVID-19 vaccination through UPMC or visit a non-UPMC provider or UPMC Urgent Care location.

Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

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

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   Current UPMC employees must apply in HR Direct

Quality Assurance Reviewer II-Claims (Remote)

Description

UPMC Health Plan's Quality Assurance Department has an exciting REMOTE opportunity for a Quality Assurance Reviewer II- Claims!

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.

Strong preferences: The candidate should have medical claims processing and reviewing experience, previous experience in the medical insurance industry, and should be familiar with Microsoft Office applications.

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.
  • Medical claims processing and reviewing experience,  previous experience in the medical insurance industry and should be familiar with Microsoft Office applications.


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

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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