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Are you passionate about quality and committed to making processes better every day? As a Claims Quality Support Specialist, you'll play a key role in ensuring our claims operations meet the highest standards of accuracy, compliance, and customer satisfaction. This is your opportunity to influence outcomes, mentor teams, and create solutions that truly make a difference.

You'll combine data analysis, process improvement, and training expertise to raise the bar on quality performance. If you thrive in a role where attention to detail meets big-picture thinking, this position is for you.

What You'll Do

+ Lead quality initiatives: Recommend and develop training materials to address quality issues and empower examiners to succeed.

+ Optimize workflows: Review HRG and CPG for clarity and accuracy, suggesting improvements that streamline processes.

+ Turn data into action: Design and maintain Quality Standard Dashboards that track impact, assess risk, and measure progress toward quality goals.

+ Create clarity: Develop cross-reference guidelines for all processes to ensure consistency and compliance.

+ Stay ahead: Keep up-to-date with guidelines, products, regulations, and policies to maintain excellence.

+ Drive collaboration: Facilitate quality meetings with stakeholders, document discussions, and track issue resolution.

+ Monitor performance: Track compliance, SLAs, and benchmarks to ensure we exceed expectations.

+ Solve problems: Analyze errors and dissatisfaction trends, then recommend solutions to improve processes, tools, and training.

+ Mentor and inspire: Serve as a trusted resource for team leaders and supervisors, guiding them toward quality success.

Why You'll Love This Role

You'll have the chance to shape quality standards, influence operational excellence, and make a tangible impact on member and provider experiences. If you're detail-oriented, proactive, and passionate about continuous improvement, we'd love to have you on our team.

There is a monthly in office requirement for this role. Additional time in office may be needed based on business needs.

+ 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 year in a healthcare setting.

+ Competent in 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;

+ Strong working knowledge of Microsoft Access and Excel Preferred;

+ 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.Licensure, Certifications, and Clearances:UPMC is an Equal Opportunity Employer/Disability/Veteran