Lead Certified Coder QAOI- Remote

Life in Pittsburgh; Pittsburgh (Allegheny County); Remote; USD 120,000 - 160,000; Full time

Job summary

UPMC Health Plan is seeking a Lead Certified Coder Quality Assurance Operational Integrity professional to oversee QA and auditing across ISD. This remote role requires CPC certification and leadership experience to drive risk management and regulatory compliance.

The candidate will mentor staff, coordinate initiatives, and ensure quality control, reporting, and stakeholder alignment across complex healthcare products and IT processes.

Qualifications

• Bachelor's 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 clinical, claim financial ties, HCC diagnosis coding, quality data science, IT process controls, IT SDLC or advanced project management preferred.
• Ability to comprehend and apply relevant information to tasks and assignments.
• Detail oriented with advanced critical thinking, analytical, and project management skills.
• Excellent oral, written, and reporting communication skills.
• 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.

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 stakeholder performance expectations and department vision, aligning 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 day-to-day activities and provide guidance/assistance, including 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 related to their work.
• Maintain department policies, procedures, guidelines and ensure QAOI internal integrity.
• Evaluate and document stakeholder needs, current processes and revisions.
• Assist with complex QAOI projects/initiatives/reviews with superior auditing processes.

Skills

Leadership

Quality assurance

Auditing

Risk management

Communication skills

Data analysis

MS Teams

MS Excel

Education

Bachelor's degree or equivalent

CPC Certification

CIA certification preferred

Tools

Visio

Auditing software

Data extraction tools

Job description

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

The Lead Certified Coder QAOI 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