[Hiring] Clinical Auditor/Analyst Intermediate @UPMC

Role Description

UPMC Health Plan is hiring a full-time Clinical Auditor/Analyst Intermediate position to support the Fraud, Waste & Abuse team. This is a full-time position working Monday through Friday daylight hours and will be remote.

The Clinical Auditor/Analyst Intermediate 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
• Resource utilization

This role also acts as a Subject Matter Expert (SME) for the department in representing management in meetings, training new staff, and auditing peers. Responsibilities include:

• Collecting program data to monitor/ensure compliance requirements
• Establishing and revising best practices within the department
• Creating, maintaining, and analyzing auditing reports related to their assigned work plan
• Communicating results with management
• Analyzing controlled substance prescribing and utilization
• Prepayment review of claims and unlisted codes
• Working in collaboration with appropriate Health Plan departments
• Interacting with providers, law enforcement, and regulatory entities

Qualifications

• Registered Nurse (RN)
• Bachelor of Science in Nursing (BSN) or equivalent combination of education, professional training, and work experience
• Five years of clinical experience
• Three years of fraud & abuse, auditing, case management, quality review, or chart auditing experience required
• Inpatient coding experience highly preferred
• Ability to analyze data and maintain designated production standards
• 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 required
• Registered Nurse (RN)
• Act 31 Child Abuse Reporting with renewal
• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance with renewal
• Current licensure either in the state where the facility is located or a multistate license issued by a participating NLC state

Benefits

• Maintain or exceed designated quality and production goals
• Maintain employee/insured confidentiality