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UPMC Quality Assurance Analyst, Associate (Remote) in Pittsburgh, Pennsylvania


UPMC Health Plan is seeking a Quality Assurance Analyst, Associate to join the team!

The Quality Assurance Analyst, Associate is primarily responsible for the review of high-dollar claims and associated reporting.


  • Claims processing or auditing experience.

  • High level of written and oral communication skills.

  • Knowledge of hospital reimbursement delivery systems or insurance reimbursement.


  • Maintains employee/insured confidentiality.

  • Understands customers including internal Health Plan Departments (i.e. claims staff, customer service, Marketing, etc.) and external customers (i.e. Health System Internal Audit, Client Audit teams) and responds to customers' requests.

  • Audits high-dollar claims on a prospective and/or retrospective basis.

  • Works with Reimbursement and Configuration Specialists to ensure correct payments and identify/resolve payment inaccuracies.

  • Assesses, investigates and resolves difficult issues to ensure customer satisfaction.

  • Compiles and reports statistical data to internal and external customers.

  • Participates in all training programs to develop a thorough understanding of the materials presented to the claim and service staff.

  • Leads process improvement activities, targets potential problems.

  • Identifies root causes and associated error trends to determine appropriate training needs and suggest modifications to policies and procedures.

  • Devises sampling methodology and retrieves audit samples from appropriate sources

This is a work-from-home position .


  • High school and 4 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 required.

  • 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.e. Excel, MS access, COGNOS).

  • Detail-oriented individual with excellent organizational skills.

  • High level of oral and written communication skills.

  • Intermediate proficiency with Excel.

  • Intermediate proficiency with MS Office products.

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

REQNUMBER: 555433758