Quality Analyst, Intermediate-Claims & Process Improvement

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 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.