Certified Coder QAOI, Lead (Hybrid)- Pittsburgh, PA

UPMC; Pittsburgh (Allegheny County); On-site; USD 100,000 - 140,000; Full time

Job summary

UPMC Health Plan is seeking a Certified Coder Quality Assurance Operational Integrity Lead for a full-time hybrid role with daylight hours, Monday–Friday. Leads QA/operational integrity reviews across ISD products and departments, guiding teams to mitigate risk and ensure regulatory compliance.

The role requires CPC certification, a bachelor’s degree or equivalent experience, and strong leadership in healthcare QA, IT, and data-driven risk management.

Qualifications

• Bachelor's degree or equivalent professional experience in a relevant field.
• CPC Certification is required for consideration.
• CIA certification preferred and healthcare knowledge is highly valued.
• 7+ years of related experience in quality assurance, operational controls, risk management, auditing, or customer service.

Responsibilities

• Serves as a positive extension of the leadership team, protects the department's brand and reputation, and contributes to a positive QAOI work community.
• Educates QAOI and ISD leadership on best-in-class risk management protocol.
• Mentors and coaches senior QAOI professionals.
• Lead and/or participate on workgroups/projects/initiatives to drive results.
• Understand stakeholder expectations and align responsibilities with the department vision and objectives.
• Demonstrate value added by capturing cost-benefit analysis.
• Distribute work assignments and manage team workload.
• Oversee day-to-day activities and coordinate new staff orientation.
• Provide training and support as needed and act as process and technical expert.
• Assume manager support and quality control as needed.
• Help professionals resolve complex challenges related to their work.
• Maintain department policies, procedures, guidelines and ensure operational integrity.
• Evaluate and document stakeholder needs and proposed revisions.
• Assist with complex QAOI projects ensuring superior auditing processes and risk management.
• Generate succinct report findings and workpapers; conduct quality reviews of staff outcomes.

Skills

Leadership

Quality assurance

Risk management

Project management

Communication

Education

Bachelor's degree or equivalent professional experience

CIA certification preferred

Tools

MS Teams

Word

Excel

Visio

Job description

UPMC Health Plan has an exciting opportunity for a Certified Coder Quality Assurance Operational Integrity Lead position. This is a full time position working Monday through Friday daylight hours. This is a hybrid position with flexibility.

The Certified Coder QAOI, Lead will provide front line leadership to the professionals who conduct quality assurance and operational integrity assessments and reviews across the Insurance Services Divisions' portfolio of products, services, and functional departments, supporting ISD stakeholders and leadership to mitigate risks, ensure operational integrity, and compliance in the achievement of initiatives, business goals, and objectives. The QAOI Lead provides technical, employee and operations support to a diverse team of highly skilled quality assurance and operational integrity risk management professionals with functional expertise in clinical, financial, operational, healthcare, insurance products, IT protocols, business intelligence, and more. This position plays a crucial role in the prioritization and coordination of various team assignments and projects to help drive team results and operational efficiency.

To be considered for this position candidates must be a certified coder and have a CPC Certification.

Responsibilities:

• Serves as a positive extension of the leadership team, protects the departments' brand and reputation, as well as contributes to building a positive QAOI work community.
• Educates QAOI and ISD leadership on best-in-class risk management protocol.
• Mentors and Coaches Senior QAOI professional staff.
• Successfully lead and/or participate on workgroups/projects/initiatives to drive results.
• Thorough understanding of the Stakeholder performance expectations, department vision, mission, objectives and aligns responsibilities accordingly.
• Demonstrate value added by capturing cost-benefit analysis.
• Responsible for the distribution of work assignments for the team, as well as workload management.
• Oversee the day-to-day activities and provides guidance/assistance, as necessary including coordination of new staff orientation.
• Serve as a process and technical expert, providing training and support as needed.
• Assume manager support and quality control as needed.
• Help professionals resolve complex challenges/issues related to their work.
• Maintain department policies, procedures, guidelines and ensures the integrity QAOI internal operations.
• Evaluate and document stakeholder needs, including current processes and proposed revisions.
• Assist with most complex QAOI projects/initiatives/reviews executing superior auditing processes, best in class risk management, or project management skills.
• Excels at generating succinct report findings and workpapers.
• Conducts quality reviews of professional staff outcomes.
• Will cover workloads as appropriate.

• Bachelors degree or equivalent professional experience, along with 7 years of related experience in quality assurance, operational controls, risk management, auditing, or customer service.
• CIA certification preferred.
• 1 year experience leading or facilitating meetings.
• 1 year experience coaching and mentoring. Strong knowledge of a healthcare portfolio of products, services, and/or functional departments or experience auditing in a heavily regulated industry required.
• Healthcare specialization in any of the following disciplines strongly preferred:
• Clinical, claim financial ties, HCC diagnosis coding, quality data science, IT process controls, IT SDLC or advanced project management.
• Ability to comprehend and apply relevant information to tasks and assignments.
• Detailed oriented with advanced critical thinking skills, advanced analytical skills, and advanced project management skills.
• Excellent oral, written, and reporting communication skills.
• Must possess a professional demeanor with the ability to manage multiple priorities and meet deadlines required.
• Proficiency using MS Teams, Word, and Excel.
• Ability to learn Visio and auditing technology.
• Ability to apply data extraction and leverage data extraction tools.Licensure, Certifications, and Clearances:CIA, Six Sigma, PM, or SAFe preferred. UPMC is an Equal Opportunity Employer/Disability/Veteran