Healthcare Compliance Auditor, Senior I

UPMC; Pittsburgh (Allegheny County); Hybrid; USD 85,000 - 120,000; Full time

Job summary

UPMC is seeking a Healthcare Compliance Auditor Senior I to support compliance and regulatory oversight by identifying and mitigating healthcare compliance risks. The role combines remote work with on-site attendance at the USX office, balancing clinical, revenue cycle, and compliance priorities.

You will review medical terminology, HIM coding, and reimbursement practices; research Medicare/Medicaid rules; and document audit workpapers, findings, and corrective actions.

Qualifications

• Knowledge of medical terminology, HIM coding, and reimbursement methodologies.
• Understanding of internal policies and external regulatory requirements (Medicare, Medicaid, DOH).
• Ability to interpret federal and state healthcare regulations and payer requirements.

Responsibilities

• Identify potential compliance risks in billing and documentation.
• Research Medicare/Medicaid and other regulatory requirements affecting billing and compliance.
• Review clinical documentation, coding, billing, and reimbursement practices for gaps.
• Collaborate with clinical, operational, revenue cycle, and compliance stakeholders.
• Maintain audit workpapers and supporting documentation per standards.
• Develop and deliver compliance education and training on audit findings.

Skills

Medical terminology

HIM coding

Regulatory compliance

Cross-functional communication

Job description

The Healthcare Compliance Auditor Senior I plays a key role in supporting UPMC's compliance and regulatory oversight activities through the identification, assessment, and mitigation of healthcare compliance risks. Leveraging expertise in healthcare operations, reimbursement methodologies, and regulatory requirements, this position conducts auditing and monitoring activities and collaborates with clinical, operational, revenue cycle, and compliance stakeholders to promote adherence to regulatory requirements. This is a full-time position that works Monday through Friday during normal business hours. The role follows a hybrid work model, with a combination of remote work and on-site attendance at UPMC's USX office.

Responsibilities

• Must have knowledge of medical terminology, HIM coding, and reimbursement methodologies.
• Has working knowledge of internal policies and external regulatory requirements (e.g., Medicare, Medicaid, DOH, and other applicable authorities).
• Conducts independent research on Medicare, Medicaid, and other regulatory requirements impacting billing and compliance.
• Understands patient flow and care in a clinical setting, healthcare billing and healthcare compliance issues.
• Reviews clinical documentation, coding, billing, and reimbursement practices to identify potential compliance risks and opportunities for improvement.
• Monitors and validates the implementation of corrective actions to ensure sustained compliance.
• Conducts follow-up reviews to validate the effectiveness and sustainability of corrective action plans.
• Collaborates with clinical, operational, revenue cycle, and compliance stakeholders to evaluate processes and ensure adherence to regulatory requirements and organizational standards.
• Supports compliance risk assessments and reviews, as assigned.
• Maintains detailed audit workpapers and supporting documentation in accordance with departmental standards.
• Develops and delivers compliance education and training related to audit findings.
• Monitors regulatory updates and industry guidance to identify emerging risks and assess organizational impact.
• Interprets and applies federal and state healthcare regulations, payer requirements, coding guidelines, and organizational policies to audit activities.
• Maintains effective verbal and written communication skills with the ability to engage stakeholders across all organizational levels.
• Contributes to the department’s reputation through high-quality work, collaboration, and adherence to compliance principles.