Job ID: J126474
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jun 26, 2018
The Quality analyst is responsible for compiling and analyzing data relevant to the handling of all types of complex adjusted claims; conducting reviews of all organizational or functional activities related to fraud/abuse perpetrated by providers, subscribers, facilities, pharmacies, provider employees and/or employees of the company and ensuring Highmark compliance with all adjustment processes based on SOX remediation and Regulatory and legal guidelines. In addition, the Analyst will identify potential areas of processing vulnerability through procedure review and report trending/analysis; generate reports for analysis and/or sampling; review audit samples for accuracy and appropriateness; train operational staff on processes, act as the subject matter expert for all audit adjustment processes for workgroups, recommend and implement process changes, and coaching quality review staff. As a result of the analysis and sampling activity, the position will develop reports detailing the findings and trending results on a monthly basis while also recommending any processing enhancements and/or internal control improvements.
Minimum Education and Experience
Preferred Education and Experience
Knowledge, Skills and Abilities
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? No
Is Travel Required? No
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
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