Clinical Auditor/Analyst (Remote)- Fraud, Waste and Abuse

UPMC•Pittsburgh, PA

5d•Remote

About The Position

UPMC Health Plan is hiring a Clinical Auditor/Analyst for its Fraud, Waste & Abuse department. This full-time, remote position works Monday through Friday during daylight hours and is an integral part of the Special Investigations Unit (SIU). The role conducts clinical audits and reviews involving care and services, clinical guidelines, coding, regulatory requirements, and resource utilization. It also creates, maintains, and analyzes audit reports and communicates findings to management. The position includes analyzing controlled-substance prescribing and utilization, reviewing claims before payment—including claims with unlisted codes—and using fraud and abuse detection software. The Clinical Auditor/Analyst collaborates with Health Plan departments such as Quality Improvement, Legal, and Medical Management to resolve issues and cases. Reviews may span multiple lines of business or be conducted on an ad hoc basis, and may include provider and physician billing analysis, trend analysis, and reporting. The role routinely interacts with providers, law enforcement, and regulatory entities.

Requirements

Registered Nurse (RN).
Five years of clinical experience.
Two years of experience in fraud and abuse, auditing, case management, quality review, or chart auditing.
Ability to analyze data, meet 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 multiple lines of business.
Detail-oriented, with excellent organizational skills.
Keyboard dexterity and accuracy.
Strong oral and written communication skills.
Proficiency with Microsoft Office products, including Excel, Access, OneDrive, OneNote, and Word.
Current RN licensure in the state where the facility is located, or a multistate license issued by a participating Nursing Licensure Compact state when the facility is in an NLC state. Employees working on an out-of-state NLC license who change residency to the facility's state must apply for licensure there within 60 days.

Nice To Haves

AAPC or AHIMA certification, such as CPC, CPMA, CIC, CCA, CCS, or CCS-P, or an AHFI designation.

Responsibilities

Respond to fraud, waste, and abuse referrals and complete assigned data analysis and audits.
Use fraud detection software to assess and monitor potential fraud, waste, and abuse.
Review and analyze claims, medical records, and related processes for appropriate coding, clinical care, documentation, and compliance with Health Plan business rules.
Provide clinical opinions for special projects and issues, including controlled-substance utilization and prescribing and the medical appropriateness of services.
Query medical and pharmacy claims and conduct risk assessments using data analysis, applicable coding guidelines, Health Plan policies, and relevant National or Local Coverage Determinations.
Evaluate Pharmacy Benefit Manager referrals by analyzing claims and clinical documentation in HealthPlaNET, Mars, Epic, and/or Cerner.
Complete audits using standard coding guidelines, principles, and coding clinics to verify that CPT codes or DRGs are supported by medical-record documentation.
Attend recipient restriction hearings in person or virtually.
Review Medical Pended Queue claims and resolve referral issues through research and collaboration with Medical Management, Medical Directors, committees, and other Health Plan departments.
Assist with developing policies concerning future Health Plan payment of identified issues.
Assess, investigate, and resolve low- to intermediate-level issues.
Prepare concise written reports, including statistical data, describing issues, their effects on the Health Plan, and recommended resolutions.
Identify error trends, determine training needs, and recommend changes to company policies and procedures.
Conduct provider education regarding audit results when necessary.
Communicate with Medical Directors and ancillary departments to address issues and concerns.
Work with internal and external customers to understand issues, identify solutions, and facilitate resolution.
Represent the SIU at internal and external meetings; document and present findings to SIU staff and record information in the SIU FWA Case Management Database as appropriate.
Assist in developing and revising SIU policies and procedures.
Design and maintain reports, auditing tools, and related documentation.
Participate in training programs to develop a thorough understanding of presented materials.
Obtain continuing education credits to maintain a nursing license and/or professional designations.
Meet or exceed designated quality and production goals.
Maintain employee and insured confidentiality and comply with HIPAA regulations.