QA Analyst, Intermediate (Hybrid) - Pittsburgh, PA

About the role

The QA Analyst, Intermediate conducts quality assurance and operational integrity assessments across the Insurance Services Division’s 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 with experience in Archer or another GRC system will be highly considered. Familiarity with Medicare Part C operations (Claims, Medical Management, Complaints & Grievances) and Medicare Enrollment audit is sought.

Responsibilities

• Audit Competency: Execute the audit process, apply the risk management framework, and select and apply appropriate statistical methodology for population samples and confidence levels
• Meet department standards for quality and internal operational integrity
• Accurately, thoroughly, and timely complete audit assignments
• Utilize source documentation to assess appropriate outcomes, integrity, and root cause on assigned targeted and focused audits
• Perform root cause analysis and recommend appropriate remedial actions to mitigate future risk
• Government Products: Perform regular audits on 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
• Serve as backup for Medicare Enrollment
• Conduct Creditable Coverage Letter Reviews (ad hoc)
• Assess Compliance Program Effectiveness

Requirements

• High school diploma 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 relevant experience
• 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 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 GRC system preferred