UPMC · 1 month ago
Clinical Auditor/Analyst (Remote)- Fraud, Waste and Abuse
United States
Full-time
Remote
Senior Level
5+ years expUPMC Health Plan has an exciting opportunity for a Clinical Auditor/Analyst position in the Fraud, Waste & Abuse department. The role involves conducting clinical audits and reviews, analyzing care and services related to clinical guidelines and coding requirements, and collaborating with various Health Plan departments to resolve issues.
BiotechnologyHealthcareHospitalHealth CareMedical
No H1B
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 low to intermediate 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
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
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 and adhere to HIPAA regulations
Qualification
Required
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)
Preferred
Experience in mental health claims review and laboratory claims review is highly preferred!
AAPC or AHIMA Certified (CPC, CPMA, CIC, CCA, CCS, CCS-P) or AHFI designation preferred
Company
UPMC
UPMC is one of the leading nonprofit health systems in the United States. A $10 billion integrated global health enterprise headquartered
10001+ employees
Funding
Current Stage
Late StageTotal Funding
$0.46MKey Investors
Appalachian Regional Commission
2024-09-18Grant· $0.46M
Leadership Team
Leslie Davis
Chief Executive Officer
Frederick M. Hargett
Chief Financial Officer
Recent News
2026-07-10
2026-07-01
Modern Healthcare
2026-06-11
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