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UPMC · 2 days ago

Clinical Auditor/Analyst Intermediate - Remote

United States

Full-time

Remote

Mid, Senior Level

5+ years exp

UPMC Health Plan has an exciting opportunity for a Clinical Auditor/Analyst Intermediate. This role is responsible for conducting clinical audits and reviews regarding care and services related to clinical guidelines, coding requirements, and regulatory requirements, while also acting as a subject matter expert for the department.

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Responsibilities

Respond to fraud, waste, and abuse referrals and/or complete data analysis and related audits as assigned

Utilize fraud detection software to assess and monitor for potential FWA

Review and analyze claims, medical records and associated processes related to the appropriateness of coding, clinical care, documentation, and health plan business rules

Provide a clinical opinion for special projects or various issues including appropriate utilization of controlled substances, prescribing of controlled substances, or medically appropriate services

Query medical and/or pharmacy claims and conduct a risk assessment by performing data analysis and applying applicable coding guidelines, Health Plan policies and any applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD)

Evaluate referrals from Pharmacy Benefit Manager (PBM) by analyzing medical and pharmacy claims and associated clinical documentation in HealthPlaNET, Mars, Epic and/or Cerner

Complete audits by utilizing standard coding guidelines and principles and coding clinics to verify that the appropriate CPT codes/DRGs were assigned and supported in the medical record documentation

Attend in person or virtual recipient restriction hearings

Review Medical Pended Queue claims to understand and resolve claim referral issues through research and interaction with other Health Plan Departments including Medical Management, Medical Directors, various committees, and other appropriate Health Plan departments

As necessary, assist in the development of new policies concerning future Health Plan payment of identified issue

Assess, investigate and resolve complex issues

Write concise written reports including statistical data for communication to other areas of UPMC Health Plan and to communicate with department heads for identification of various problem issues, how they affect the Health Plan, and to make recommendations for resolution of the issue

Identify error trends to determine appropriate training needs and suggest modifications to company policies and procedures

Conduct provider education, as necessary, regarding audit results. Communicate effectively with Medical Directors and ancillary departments as necessary to address issues and concerns

Participate as needed in special projects and other auditing activities. Provide assistance to other departments as requested

Understand customers including internal Health Plan Departments (i.e. Claims staff, Customer Service, Marketing, etc.) and external customers (i.e. Health System Internal Audit, Client Audit teams) to understand issues, identify solutions and facilitate resolution

Serve as an SIU representative at internal and external meetings, document and present findings to SIU Staff and document as appropriate in the SIU FWA Case Management Database

Assist in the development and revision of SIU policies and procedures. Identify trends for improvements internally, such as claims payment, to determine appropriate training needs and suggest modification to company policies and procedures

Perform audit peer reviews for Clinical Auditor/Analysts

Provide new-hire training to Clinical Auditor/Analysts. Performing administrative appeals/preparing medical necessity appeals for Medical Directors for second level appeals. Participate in training programs to develop a thorough understanding of the materials presented

Obtain CPE or CEUs to maintain nursing license, and/or professional designations

Design and maintain reports, auditing tools and related documentation. Maintain or exceed designated quality and production goals. Maintain employee/insured confidentiality

Qualification

Fraud detection softwareICD-10 codingCPT-4 codingClinical auditingData analysisHealth insurance knowledgeMicrosoft Office proficiencyKeyboard dexterityTraining skillsOrganizational skillsCommunication skillsDetail-orientedTeam collaboration

Required

Registered Nurse (RN). Bachelor of Science in Nursing (BSN) or the 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

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)

AAPC or AHIMA Certified (CPC, CPMA, CIC, CCA, CCS, CCS-P) or AHFI designation required

Registered Nurse (RN)

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, 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