AVP, Quality Assurance & Operational Integrity

The UPMC Health Plan is seeking a results-oriented, transformational 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.

The Associate Vice President (AVP), Quality Assurance & Operational Integrity reports to the Senior Vice President, Chief Risk, Compliance & Ethics Officer of UPMC Insurance Services and strategically and operationally leads 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 role 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. The AVP, Quality Assurance & Operational Integrity evaluates statistical patterns and trends of quality assurance results and collaborates with owners of audited business areas to address root causation of errors and facilitate overall quality improvement.

This role is Hybrid and will require a minimum of 3 days in-person in Downtown Pittsburgh .

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.
• Updates and ensures protocols and controls are followed, while keeping abreast of changing industry requirements, compliance responsibilities, and regulations.
• 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 practices.
• 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.
• Ensures strategic and operational partnership and collaboration with the business and operational areas, as well as with sibling Governance, Risk & Compliance (GRC) teams to leverage cross-departmental synergy and efficiencies.
• Develops, chairs, and leads Quality Assurance & Operational Integrity committees and working groups.
• Owns and performs strategic planning, goal planning, budget planning and management, performance review, professional development, and all other executive-level managerial functions.
• Develops processes for identifying emerging trends through data gathering and analysis, including industry relevant AI, machine learning, data analytics, scripting, and other such automated tools, and for designing appropriate methods and tools for visual representation of analyzed data to identify trends, patterns, and results to enable effective Board and executive leadership communication and reporting.
• 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.
• Informs and advise SVP, Chief Risk, Compliance & Ethics Officer of current trends, issues, problems, and activities in functional areas, and develop and implement appropriate interventions to facilitate problem resolution and policy making.
• Plans, executes, and evaluates results of audits/reviews and operational integrity initiatives, evaluating error patterns and trends, and ensuring the reporting of relevant audit/review results, pre-payment and post-payment claim reviews, and evaluation of HCC audits/reviews, among others, to relevant departments.