Quality Assurance Operational Integrity Associate (Risk)

UPMC Health Plan is hiring a full-time Quality Assurance Operational Integrity Associate to support our Operational Risk Integrity department.

In this role, you will conduct quality assurance and operational integrity assessments and reviews across the Insurance Services Divisions' portfolio of products, services, and functional departments. In this role you will be supporting ISD stakeholders and leadership to mitigate risks, ensure operational integrity, and compliance in the achievement of initiatives, business goals, and objectives. As the QAOI, you will be primarily responsible for planning, executing, and reporting on the assigned scope of work, including claim reviews under credit balance, Vendor Management, claim data analytics, conducting root cause analysis on all review types and be responsible for business/financial/operational controls, which includes preparing actionable data reports that provides insight and value to ISD Stakeholders.

Responsibilities:

• Successfully demonstrate competency in executing the claim audit process, process via credit balance reviews and data analytics
• Meets departmental standards for quality and internal operational integrity.
• Demonstrates accurate, thoroughly, and timely completion of assignments.
• Actively building an internal network of partners and SMEs across the ISD, as well as maintaining a positive/value add relationship with the IDS Vendors and Central Billing Office,
• Contribute to a positive QAOI work community modeling department tenets, as well assisting in identifying opportunities for process improvements within the department.

• Readily identifies and uses source documents to assess appropriate outcomes, integrity, root causes and value add on all claim reviews, which impacts business/financial/operational/IT controls.

• Defines scope, verify requirements/deliverables for review activity including planning coordinating, participating in meetings, and following through to assignment completion (including mock audits).
• Prepares accurate and thorough actionable data reports /workpapers with consistent correct spelling, grammar, and organization.
• Successfully demonstrates and implements value add to the department and ISD from findings within claims and data analytic reviews.
• Tracks and performs follow-up for past work.
• Participates in workgroups
• Successfully interacts and establishes credibility with stakeholders including maintaining independence and selecting the appropriate meeting formats.
• Understands the organization structure and how applies to work, as well as ISD initiatives that may impact work.

Qualifications:

• Bachelor's degree and/or equivalent experience.
• 5 years' experience (quality assurance, operational controls, risk management, auditing, or customer service) or CIA certification with 1 years related experience quality assurance, operational controls, risk management, auditing, or customer service.
• Previous experience with medical claims and claims data analytics highly preferred.
• Previous vendor management experience
• Familiarity with a healthcare portfolio of products, services, and/or functional departments or experiencing auditing in a heavily regulated industry preferred.
• Ability to comprehend and apply relevant information to tasks and assignments.
• Detailed oriented with strong critical thinking skills, analytical skills, and basic project management skills.
• Excellent oral, written, and reporting communication skills.
• Must possess a professional demeanor with the ability to manage multiple priorities and meet deadlines required.
• Proficiency using MS Teams, Word, and Excel. Ability to learn Visio and auditing technology.

Licensure, Certifications, and Clearances:

• CIA preferred
• Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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