Job details
Job type full-time
Full job description
Description
Upmc health plan`s quality assurance department is seeking a quality assurance analyst- intermediate!
The insurance auditor intermediate is responsible for the review and reporting of high-dollar claimsThis auditor also participates in higher-level auditing activities such as focused audits of operational, regulatory, and other controlsThe person who will fill this role must have claims processing experience.
This is a work-from-home position, ideally in western, 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.
Assists 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.
Serve 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.
Audits high dollar claims on a prospective and/or retrospective basis.
Leads process improvement activities, target potential problems.
Understands customers including internal health plan departments (i.eClaims staff, customer service, marketing, etc.) and external customers (i.eHealth system internal audit, client audit teams) and respond to customers` requests.
Works with reimbursement and configuration specialists to ensure correct payments and identify/resolve payment inaccuracies.
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.
Must have claims processing experience.
Basic understanding of managed care delivery systems.
Experience and knowledge of reimbursement mechanisms and clinical/procedural coding or five years of claims processing experience, including commercial and government health insurance plans and other insurance/network products.
Excellent analytical skills, familiarity with basic statistical analysis, and proficiency in utilizing pc based applications (i.eExcel, ms access, cognos).
Detail-oriented individual with excellent organizational skills.
High level of oral and written communication skills.
Advanced proficiency with excel.
Intermediate to advanced proficiency with ms office products and extensive pc skills.
Acl or similar software proficiency preferred.
Licensure, certifications, and clearances:
Upmc is an equal opportunity employer/disability/veteran
