QA Analyst, Intermediate (Hybrid) Pittsburgh, PA

Job Description
On behalf of VetJobs/MilitarySpouseJobs thank you for your interest. We are assisting our partnering company listed below with this position. It is open to Veterans Transitioning Military National Guard Members Military Spouses Wounded Warriors and their Caregivers. If you have the required skill set education requirements and experience please click the submit button and follow for next steps.


Job ID:
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Work Arrangement: Hybrid
Facility: UPMC Health Plan
Department: OperationalRiskIntegrity
Location: 600 Grant St Pittsburgh PA
Union Position: No
Salary Range: $ 27.89-48.21 USD

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. We are also looking for candidates with CDAG ODAG SNP model of Care CPE and Medicare Enrollment audit. Pharmacy experience is a plus.

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:

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.
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.
Partners with the ISDs compliance teams to mitigate risk across all government products
Performs regular operational audits on the following products and operational environments:
Medicare Organization and Coverage Determinations Appeals and Grievances (CDAG and ODAG)
Medicaid and CHC Pharmacy
Medicare Formulary Administration
Medicare and SNP Medical Dental Vision and Pharmacy claims and direct member reimbursements
Serves as a representative on Second Level Appeal and Grievance hearing committees
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
Qualifications:

High school and 5 years of claims processing experience in physician ancillary and/or hospital reimbursement delivery systems or insurance reimbursement including subrogation and overpayment recovery
or a Bachelors degree and 1 year of experience required.
Basic understanding of managed care delivery systems.
Experience and knowledge of reimbursement mechanisms Medicare products and/or five years of claims processing enrollment and/or pharmacy operations experience including government health insurance plans.
Experience with CDAG ODAG SNP Model of Care CPE and Medicare Enrollment audits is highly preferred
Basic understanding of SOC1 SSAE and SOX controls
Excellent analytical skills and familiarity with basic statistical analysis
Detail-oriented individual with excellent organizational skills.
High level of oral and written communication skills with demonstrated business writing experience highly preferred
Intermediate to advanced proficiency with MS Office products and extensive PC skills particularly in Microsoft Word and Excel.
Experience with Archer or another GCR system preferred
Licensure Certifications and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran