QA Analyst, Intermediate (Hybrid) - Pittsburgh, PA

This is a full-time, hybrid position located in downtown Pittsburgh, PA, requiring 3 days in the office and 2 days at home, with a schedule of Monday through Friday during daylight hours.

About the Role

The QA Analyst, Intermediate conducts quality assurance and operational integrity assessments across the Insurance Services Divisions’ portfolio of products, services, and functional departments. This role also participates in higher-level auditing activities, including focused audits of operational, regulatory, and other controls. Candidates with experience in Archer or another GRC system are highly preferred.

Responsibilities

• Audit Competency:
  • Demonstrate competency in executing the audit process and risk management framework.
  • Select and apply appropriate statistical methodology for population samples and confidence levels.
  • Meet department standards for quality and internal operational integrity.
  • Complete audit assignments accurately, thoroughly, and timely.
  • Utilize source documentation to assess outcomes, integrity, and root cause for targeted and focused audits.
  • Perform root cause analysis and recommend remedial actions to mitigate future risk.
• Government Products:
  • Perform regular audits on the following products and environments:
    • 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 and 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 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 strong organizational skills.
• High level of oral and written communication skills; demonstrated business writing experience is highly preferred.
• Intermediate to advanced proficiency with MS Office products, particularly Microsoft Word and Excel.
• Experience with Archer or another GRC system is preferred.

Licensure, Certifications, and Clearances

Relevant certifications or clearances may be required (details not specified in the posting).