Quality Assurance Analyst

QA Analyst, IntermediateThe 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. 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:Successfully demonstrates competency in executing the audit process, risk management framework, selecting and applying appropriate statistical methodology for population samples and confidence levelsMeets department standards for quality and internal operational integrityDemonstrates accurate, thoroughly, and timely completion of audit assignmentsUtilizes source documentation to assess appropriate outcomes, integrity, and root cause on assigned targeted and focused auditsPerforms root cause analysis and recommends appropriate remedial actions to mitigate future riskGovernment Products:Part C TimelinessMedicare and SNP Medical ManagementMedicare and SNP ClaimsMedicare and SNP DMR MedicalMedicare and SNP Dental and Vision ClaimsMedicare and SNP Complaints & GrievancesSNP Model of CareServes as Backup for Medicare EnrollmentCreditable Coverage Letter Reviews (ad hoc)Compliance Program EffectivenessHigh 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 preferredBasic understanding of SOC1, SSAE, and SOX controlsExcellent analytical skills and familiarity with basic statistical analysisDetail-oriented individual with excellent organizational skills.High level of oral and written communication skills with demonstrated business writing experience highly preferredIntermediate to advanced proficiency with MS Office products and extensive PC skills, particularly in Microsoft Word and Excel.Experience with Archer or another GCR system preferredLicensure, Certifications, and Clearances: UPMC is an Equal Opportunity Employer/Disability/Veteran