QA Analyst, Intermediate (Hybrid)- Pittsburgh, PA

UPMC•Pittsburgh, PA

2d•Hybrid

About The Position

UPMC Health Plan is seeking a Quality Analyst, Intermediate for the QAOI department. This full-time hybrid position is based at the US Steel Tower in Pittsburgh, Pennsylvania, with work from home and in-office work three days per week. The schedule is Monday through Friday during daylight hours. The Quality Analyst reviews and reports on high-dollar claims and participates in higher-level auditing activities, including focused audits of operational, regulatory, and other controls. The role supports accurate reimbursement, quality assurance, customer satisfaction, and process improvement through auditing, reporting, investigation, and collaboration with internal and external customers.

Requirements

High school diploma and five years of claims processing experience in physician, ancillary, and/or hospital reimbursement delivery systems or insurance reimbursement, including subrogation and overpayment recovery; alternatively, a bachelor's degree and one year of 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 with PC-based applications such as Excel, MS Access, and COGNOS.
Detail-oriented with excellent organizational skills.
Strong oral and written communication skills.
Advanced proficiency with Excel.
Intermediate to advanced proficiency with MS Office products and extensive PC skills.

Nice To Haves

Proficiency with ACL or similar software.

Responsibilities

Design and maintain reports, auditing tools, databases, and related documentation.
Maintain employee and insured confidentiality.
Participate in higher-level auditing activities, including focused audits of operational, regulatory, and other controls.
Devise sampling methodology and retrieve audit samples from appropriate sources.
Assist in developing and revising QA department policies and procedures.
Compile and report statistical data to internal and external customers.
Assess, investigate, and resolve difficult issues to ensure customer satisfaction.
Identify root causes and error trends to determine training needs and suggest modifications to policies and procedures.
Represent the QA Department at internal and external meetings; document and present findings to QA staff.
Participate in training programs to develop a thorough understanding of materials presented to claim and service staff.
Audit high-dollar claims on a prospective and/or retrospective basis.
Lead process improvement activities and target potential problems.
Understand internal Health Plan departments and external customers, and respond to their requests.
Work with Reimbursement and Configuration Specialists to ensure correct payments and identify and resolve payment inaccuracies.