QA Analyst, Associate- Hybrid - Pittsburgh, PA at UPMC

Pittsburgh, Pennsylvania, United States -

Full Time

Start Date

Immediate

Expiry Date

01 Mar, 26

Salary

0.0

Posted On

01 Dec, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Processing, Analytical Skills, Statistical Analysis, Excel, MS Access, Cognos, Organizational Skills, Communication Skills, Reimbursement Mechanisms, Clinical Coding, Procedural Coding, Managed Care Delivery Systems, Problem Solving, Process Improvement, Confidentiality, Customer Service

Industry

Hospitals and Health Care

Description

UPMC Health Plan has an exciting opportunity for a QA Anlyst, Associate in the Operatonal Risk Integrity department. This is a full time position working Monday through Friday daylight hours. The will be a hybrid shift consisting of working from home and in the office two days per week. The Insurance Auditor Associate is primarily responsible for the review of high dollar claims and associated reporting. Responsibilities: Maintains employee/insured confidentiality. 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. Audits high dollar claims on a prospective and/or retrospective basis. Works with Reimbursement and Configuration Specialists to ensure correct payments and identify/resolve payment inaccuracies. Assesses, investigates and resolves difficult issues to ensure customer satisfaction. Compiles and reports statistical data to internal and external customers. Participates in all training programs to develop a thorough understanding of the materials presented to the claim and service staff. Leads process improvement activities, target potential problems. Identifies root causes and associated error trends to determine appropriate training needs and suggest modifications to policies and procedures. Devises sampling methodology and retrieves audit samples from appropriate sources. High school and 4 years of claims processing, experience in physician, ancillary and/or hospital reimbursement delivery systems or insurance reimbursement, including subrogation and overpayment recovery or a Bachelor's degree required. Basic understanding of managed care delivery systems. Experience and knowledge of reimbursement mechanisms and clinical/procedural coding or five years of claims processing experience, including commercial and government health insurance plans and other insurance/network products. Excellent analytical skills, familiarity with basic statistical analysis, and proficiency in utilizing PC based applications (i.e. Excel, MS access, COGNOS). Detail-oriented individual with excellent organizational skills. High level of oral and written communication skills. Intermediate proficiency with Excel. Intermediate proficiency with MS Office products. Licensure, Certifications, and Clearances: UPMC is an Equal Opportunity Employer/Disability/Veteran

Responsibilities

The QA Analyst, Associate is responsible for reviewing high dollar claims and associated reporting. They will maintain confidentiality, respond to customer requests, and lead process improvement activities.