Claims Quality Support Spec.

UPMC•Pittsburgh, PA

About The Position

The Claims Quality Support Specialist is responsible for oversight and administration of improved quality outcomes that align with Excellence and Innovation to exceed quality and compliance standards, as well as enhance the customer/member experience. This includes data retrieval, trending, analysis and reporting, as well as partnering with Stakeholders to drive operational excellence.

Requirements

Bachelor's Degree or equivalent business experience
5 years of health insurance operations processing and/or call center/customer service experience with at least 2 years in a healthcare setting
Competent in MC400 claims process operating system
Excellent knowledge of medical terminology, ICD-9, ICD-10 and CPT coding required
Thorough knowledge of a healthcare benefit plans such as Medicaid, TPA, Medicare, and Commercial products
Thorough knowledge of claims processing including Coordination of benefits, adjustments and negative balances
Solid documentation, organizational, analytical, interpersonal, and communication skills
Competent in Microsoft Office products
A professional demeanor with the ability to manage multiple priorities and meet deadlines
Demonstrated ability to lead and/or facilitate meetings
Excellent attention to detail
Ability to develop and implement key quality metrics to measure and report on progress of initiatives

Nice To Haves

Strong working knowledge of Microsoft Access and Excel Preferred

Responsibilities

Update guidelines on SharePoint for All TPA clients
Recommend and create training materials to address quality issues
Design and maintain Quality Standard Dashboards, which include impact analysis, risk assessment, and alignment of process improvement measurements to quality outcomes
Develop cross-reference guidelines for all processes
Serve as archivist for stared drive, Gemini, ad SharePoint documentation
Generates accurate and thorough basic data retrieval to assist with trends and analysis.
Keeps abreast of all pertinent guidelines, products, regulatory, compliance, policy, and procedures.
Facilitate Quality meetings with all pertinent Stakeholders to heighten quality awareness and improved quality performance outcomes. This includes meeting documentation and tracking of issue logs.
Monitor operating performance against Compliance, Service Level Agreement, regional and national benchmarks for quality perspective.
Successfully manages all assigned projects and initiatives Develop and implement key quality metrics to measure and report on progress of initiatives.
Monitor, trend, reconcile, and quality review errors and issues leading to member/client/provider dissatisfaction, offering viable solutions to improve processes, procedures, employees' tools and training.
Serve as a quality mentor and resource for team leaders and supervisors.