[Hiring] Clinical Auditor/Analyst @UPMC

Role Description

UPMC Health Plan has an exciting opportunity for a Clinical Auditor/Analyst position in the Fraud, Waste & Abuse department. This is a full time position working Monday through Friday daylight hours and will be a remote position.

The Clinical Auditor/Analyst is an integral part of the Special Investigations Unit (SIU) and is responsible for conducting clinical audits and reviews regarding the analysis of care and services related to clinical guidelines, coding requirements, regulatory requirements, and resource utilization. The Clinical Auditor/Analyst creates, maintains and analyzes auditing reports related to their assigned work plan and communicates the results with management. Other responsibilities include but are not limited to:

• Analysis of controlled substance prescribing and utilization to identify potential clinical care issues.
• Prepayment review of claims.
• Prepayment review of unlisted codes.
• Claims analysis and the use of fraud and abuse detection software tools.
• Working in collaboration with appropriate Health Plan departments including Quality Improvement, Legal, and Medical Management.
• Multiple line of business focused reviews or ad hoc reviews as needed.
• Analysis of billing by providers/physicians.
• Providing trending, analysis and reporting of auditing data.
• Routine interaction with providers, law enforcement and/or regulatory entities.

Qualifications

• Registered Nurse (RN).
• Five years of clinical experience.
• Two years of fraud & abuse, auditing, case management, quality review or chart auditing experience required.
• Ability to analyze data, maintain designated production standards, and organize multiple projects and tasks.
• In-depth knowledge of medical terminology, ICD-10 and CPT-4 coding.
• Knowledge of health insurance products and various lines of business.
• Detail-oriented individual with excellent organizational skills.
• Keyboard dexterity and accuracy.
• High level of oral and written communication skills.
• Proficiency with Microsoft Office products (Excel, Access, OneDrive, OneNote and Word).

Requirements

• AAPC or AHIMA Certified (CPC, CPMA, CIC, CCA, CCS, CCS-P) or AHFI designation preferred.
• Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state.
• Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

Benefits

• Maintain or exceed designated quality and production goals.
• Maintain employee/insured confidentiality and adhere to HIPAA regulations.

Company Description

UPMC is an Equal Opportunity Employer/Disability/Veteran.