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.
• 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.
• Serves 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.
• 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.
• 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 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.