QA Analyst, Intermediate (Hybrid)- Pittsburgh, PA

UPMC; Pittsburgh (Allegheny County); Híbrido; USD 65.000 - 90.000; Tempo integral

Resumo da vaga

UPMC Health Plan is seeking a Quality Analyst, Intermediate in the QAOI department for a full-time, hybrid role based in Pittsburgh, PA. The position blends remote work with in-office presence three days per week at the US Steel Tower.

The QA Analyst will review and report on high-dollar claims, and participate in focused audits of operational, regulatory, and other controls, contributing to continual process improvements and policy updates.

Responsabilidades

• 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 and external customers and respond to customers' requests.
• Works with Reimbursement and Configuration Specialists to ensure correct payments and identify/resolve payment inaccuracies.

Descrição da vaga

UPMC Health Plan is seeking a Quality Analyst, Intermediate position in the QAOI department. This is a full time position working Monday through Friday daylight hours. This is a hybrid role consisting of working from home and in office 3 days per week which is located in the US Steel Tower in Pittsburgh, PA.

The Quality Analyst, Intermediate is responsible for the review and reporting of high dollar claims. This auditor also participates in higher level auditing activities such as focused audits of operational, regulatory and other controls.

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.