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. Seeking an individual who is familiar with Medicare Part C operations (i.e. Claims, Medical Management, and Complaints & Grievances) and Medicare Enrollment audit. 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:
Audit Competency
- Successfully demonstrates competency in executing the audit process, risk management framework, selecting and applying appropriate statistical methodology for population samples and confidence levels
- Meets department standards for quality and internal operational integrity
- Demonstrates accurate, thoroughly, and timely completion of audit assignments
- 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
Government Products
- Performs 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
- Serves as Backup for Medicare Enrollment
- Creditable Coverage Letter Reviews (ad hoc)
- Compliance Program Effectiveness
- 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.
- 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