QA Analyst, Intermediate (Hybrid) - Pittsburgh, PA

UPMC; Pittsburgh, Northern (Allegheny County, KY); On-site; USD 65,000 - 90,000; Full time

Job summary

UPMC in Pittsburgh seeks an Intermediate QA Analyst to conduct quality assurance and operational integrity assessments across the Insurance Services portfolio. The role covers audits of regulatory controls and Medicare Part C operations, with Archer experience highly valued.

The position is full-time, hybrid (3 days in office, 2 days remote), located in downtown Pittsburgh, PA, offering exposure to complex healthcare auditing and regulatory compliance responsibilities.

Qualifications

• Experience in quality assurance and internal audits in healthcare or insurance domains.
• Familiarity with Part C Medicare operations and enrollment audits is a plus.
• Experience with GCR systems is highly valued.

Responsibilities

• Conduct QA and operational integrity assessments across products, services, and departments.
• Participate in higher level audits of operational, regulatory, and controls.
• Apply statistical methods for population samples and confidence levels.
• Perform root cause analysis and recommend remedial actions to mitigate risk.
• Audit government products including Part C timeliness and Medicare-related claims and complaints.
• Serve as backup for Medicare Enrollment audits and review Creditable Coverage letters.

Skills

Quality Assurance

Auditing

Risk Assessment

Statistics

Root Cause Analysis

Education

Bachelor's degree in a related field

Tools

Archer

Job description

The QA Analyst, Intermediate conducts quality assurance and operational integrity assessments across the Insurance Services Divisions’ portfolio of products, services, and functional departments. This auditor also participates in higher level auditing activities such as focused audits of operational, regulatory and other controls. Candidates that have experience in Archer or another GCR system will be highly considered. Seeking an individual who is familiar with Medicare Part C operations (i.e. Claims, Medical Management, and Complaints & Grievances) and Medicare Enrollment audit. This is a Full-time position working Monday through Friday daylight hours. This is a hybrid position requiring working 3 days in office and 2 days at home. This position is located in downtown Pittsburgh, PA.

Responsibilities:

Audit Competency

• Successfully demonstrates competency in executing the audit process, risk management framework, selecting and applying appropriate statistical methodology for population samples and confidence levels
• Meets department standards for quality and internal operational integrity
• Demonstrates accurate, thoroughly, and timely completion of audit assignments
• Utilizes source documentation to assess appropriate outcomes, integrity, and root cause on assigned targeted and focused audits
• Performs root cause analysis and recommends appropriate remedial actions to mitigate future risk

Government Products

• Performs regular audits on the following products and environments:
• Part C Timeliness
• Medicare and SNP Medical Management
• Medicare and SNP Claims
• Medicare and SNP DMR Medical
• Medicare and SNP Dental and Vision Claims
• Medicare and SNP Complaints & Grievances
• SNP Model of Care
• Serves as Backup for Medicare Enrollment
• Creditable Coverage Letter Reviews (ad hoc)
• Compliance Program Effectiveness