Remote Clinical Auditor/Analyst - FWA Analytics

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 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.