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

UPMC; Pittsburgh (Allegheny County); Remote; USD 75,000 - 95,000; Full time

Job summary

UPMC Health Plan is seeking a Clinical Auditor/Analyst for the Fraud, Waste & Abuse unit. This remote, full-time role focuses on audits of care, services, coding, and regulatory compliance, with reports to SIU leadership.

You will analyze claims, review medical records, and use detection tools to identify risk areas, collaborating with Quality Improvement, Legal, and Medical Management. The ideal candidate has strong data analysis skills, clinical auditing experience, and current RN licensure.

Qualifications

• Experience conducting clinical audits and reviews against guidelines.
• Knowledge of regulatory requirements and coding rules.
• Ability to analyze claims and file documentation.

Responsibilities

• Respond to fraud, waste, and abuse referrals with data analysis.
• Use fraud detection software to monitor for potential FWA.
• Review claims, medical records, and coding for appropriateness.
• Prepare concise reports and present findings to SIU and management.
• Collaborate with Health Plan departments to resolve issues.

Skills

Data analysis

Auditing

Clinical knowledge

Communication

Education

Registered Nurse (RN) license

Tools

Fraud detection software

HealthPlaNET

Epic

Cerner

Mars

Job 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, and prepayment review of unlisted codes. Claims analysis and the use of fraud and abuse detection software tools will be an integral part of the function of this position. Responsibilities will involve working in collaboration with appropriate Health Plan departments including Quality Improvement, Legal, and Medical Management to facilitate the resolution of issue or cases. Responsibilities may involve multiple line of business focused reviews, or ad hoc reviews as needed; analysis of billing by providers/physicians, and providing trending, analysis and reporting of auditing data. The Clinical Auditor/Analyst will routinely interact with providers, law enforcement and/or regulatory entities in the course of their duties.

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.