job

About the Company:

UPMC Health Plan, headquartered in Pittsburgh, Pennsylvania, is among the nation’s fastest- growing health plans. It is owned by UPMC, a world-renowned health care provider. As part of an integrated health care delivery and delivery system, UPMC Health Plan is committed to providing its members with better health, more financial security, and the peace of mind they deserve. UPMC Health Plan partners with UPMC and community network providers to produce a combination of knowledge and expertise that provides the highest quality care at the most affordable price. The UPMC Insurance Services Division – which includes UPMC Health Plan, WorkPartners, UPMC for Life, UPMC for You, UPMC for Kids, UPMC Community Health Choices, and Community Care Behavioral Health – offers a full range of group health insurance, Medicare, Special Needs, CHIP, Medical Assistance, behavioral health, employee assistance, and workers’ compensation products and services to 3.9 million members. Their local provider network includes UPMC as well as community providers, totaling more than 140 hospitals and more than 29,000 physicians throughout Pennsylvania and parts of Ohio, West Virginia, and Maryland. For more information about UPMC Health Plan, please visit: www.upmchealthplan.com.

About the Position:

Reporting to the Senior Vice President, Chief Risk, Compliance & Ethics Officer of UPMC Insurance Services, the AVP, Quality Assurance & Operational Integrity will strategically and operationally lead various quality reviews of claims, Hierarchical Condition Categories (HCC) and clinical coding, call monitoring, system technology upgrades, and other compliance/ financial/operational controls and processes across all Insurance Services and Health Plan product lines. The AVP also leads the organization’s Focused Review & Internal Controls; SOX/MAR (Model Audit Rule) testing/assurance; Technology Assurance; and audit management, support and facilitation teams.

We are seeking a results-oriented, strong people leader, with a focus on continuous improvement. The ideal candidate will have a proven track record in operations, particularly in auditing and process improvement and should demonstrate effective leadership skills, possess the ability to build and maintain a cohesive team, and have experience in managed care, healthcare, or related fields.

Select Responsibilities:

• Develops, assesses, and adapts clear and effective Quality Assurance monitoring, audits/reviews, testing, reporting, and audit sampling methodologies to ensure proper, effective and timely assessments.
• Conducts regular assessments of existing audit reports, develops new reports as necessary, and facilitates effective remediation of findings and corrective actions.
• Provides clear and effective reports to the relevant business, functional and operational areas, as well as other internal/external stakeholders, regarding audit findings, contractual requirements, industry standards and best
• Conducts regular and ongoing risk-based evaluation of new audit/review opportunities and conducts regular evaluation of the methodology and relevance of existing audits.
• Oversees and directs regular gap analyses, risk assessments, and program effectiveness assessments for the different Quality Assurance & Operational Integrity programs and functions.
• Establishes and ensures quality standards by designing effective audits/reviews and selecting the most appropriate and effective sampling methodology to test quality on audited samples.
• Full ownership and accountability for all Quality Assurance & Operational Integrity programs, activities and reviews, including claims reviews; call center and digital communications reviews; clinical and coding reviews; technology upgrade reviews; Commercial and Government Program product compliance reviews; focused review and internal controls testing and assurance; SOX/MAR testing and assurance; audit management and facilitation; and technology and data analytics implementation and utilization, among other department activities.

Qualifications & Experience:

• Bachelor’s degree in Business Administration, Accounting, Finance or related/relevant field required; MBA, MA, and/or other advanced degree preferred.
• 12+ years of audit (internal and/or external), quality assurance/review, internal controls and assurance, risk management, corporate governance, compliance and/or related experience required, with heavy preference for highly substantive audit, assurance and internal controls experience.
• 6+ years of management and leadership experience
• Knowledge of and/or experience with regulatory and operational requirements for the delivery of health insurance products and services, including Medicare, Medicaid, SNP, CHIP, managed care, Exchange, behavioral health and commercial, as well as the associated and relevant federal, state and local regulatory entities.

About Pittsburgh:

Pittsburgh is full of natural beauty – there are 15,000 acres of public parks and green spaces in the city’s urban core and more than 13 state parks in the surrounding region. Pittsburgh has its sights set squarely on a sustainable future – Pittsburgh International Airport is pioneering a new microgrid field with eight acres of solar panels and the airport’s own natural gas. You’ll find world-class architecture in more than 90 unique neighborhoods, each with its distinctive character and charm. Residents here unwind by biking along the region’s 400 miles of trails, wandering through the lush botanic gardens, and basking in the glow of the city’s stunning fall foliage, just to name a few activities. The city is a huge player in the arts, with more than 32 museums, 30 concert venues, and 19 public libraries gifted by steel magnate and philanthropist Andrew Carnegie. Pittsburgh has a robust nonprofit and philanthropy scene, bolstered by generous residents and their donations. Plus, you’ll actually be able to enjoy all that Pittsburgh has to offer, thanks to the city’s low cost of living and doing business. The median price for a single-family home is more than 40% less than the national average.

Source: livability.com, sponsored by the PA Department of Community and Economic Development

Explore the area: visitpittsburgh.com, livability.com/pa/pittsburgh

To further explore this opportunity, express interest, or share referrals, please contact Amy Jones:

Amy Jones, Senior Executive Search Consultant
Morgan Consulting Resources ~ Healthcare Executive Search
amy@morganconsulting.com

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