QA Analyst, Intermediate (Hybrid)- 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.
• Affords assistance in the development and revision of QA department policies and procedures.
• Compiles and reports statistical data to internal and external customers.
• Affirms identification of root causes and associated error trends to determine appropriate training needs and suggest modifications to policies and procedures.
• Serves as a QA Department representative at internal and external meetings, documents and presents 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, targets 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 responds to customers' requests.
• PARTNERS WITH THE ISD’S 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

Requirements

• 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 Bachelor's 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.
• 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.

Qualifications

• Licenses, Certifications, and Clearances: UPMC is an Equal Opportunity Employer/Disability/Veteran