Remote Clinical Auditor & Analytics Specialist

UPMC; United States; Remote; USD 65,000 - 95,000; Full time

Job summary

UPMC Health Plan seeks a Clinical Auditor/Analyst to join the Fraud, Waste & Abuse team. The role focuses on clinical audits, coding accuracy, and regulatory compliance across multiple lines of business.

The analyst will work with HealthPlaNET, Mars, Epic, Cerner, and other systems to analyze claims and support investigations. The position emphasizes collaboration with Quality Improvement, Legal, and Medical Management, plus interaction with providers and regulatory entities to resolve issues

Responsibilities

• Respond to fraud, waste, and abuse referrals and perform data analysis.
• Utilize fraud detection software to monitor for potential FWA.
• Review claims, medical records, and coding for appropriateness and documentation.
• Provide clinical opinions on utilization and services.

Skills

Clinical auditing

Data analysis

Claims analysis

HIPAA compliance

Tools

Epic

Cerner

HealthPlaNET

Mars

Job description

UPMC Health Plan seeks a Clinical Auditor/Analyst to join the Fraud, Waste & Abuse team. The role focuses on clinical audits, coding accuracy, and regulatory compliance across multiple lines of business.

The analyst will work with HealthPlaNET, Mars, Epic, Cerner, and other systems to analyze claims and support investigations. The position emphasizes collaboration with Quality Improvement, Legal, and Medical Management, plus interaction with providers and regulatory entities to resolve issues