Description

UPMC Health Plan is seeking a Quality Assurance Analyst Intermediate to join their incredibly flexible, tight-knit team!

If you have Health Insurance claims processing experience, look no further! The QA Analyst Intermediate is responsible for the review and reporting of high dollar claims. This auditor also participates in higher-level audting actitivies such as focused audits of operational, regulatory, and other controls.

Preferred Experience:

• Data analytics
• Microsoft Office, Word, Excel
• Oral and Written Communication
• Healthcare claims experience
• Project Management
• Auditing experience

This is a work-from-home position. Apply today!

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 a Bachelor's degree and 1 year of experience required.
• Data analytics, Microsoft Office, Word, Excel ,Oral and Written Communication, Healthcare claims experience, Project Management, Auditing experience
• 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