Job Description

Job Title: Clinical Investigations Coordinator (RN)
Job ID: 622726
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: Community HealthChoices
Location: 600 Grant St, Pittsburgh PA 15219


The Coordinator, Clinical Audits and Investigations, coaches and develops clinical staff assigned to perform clinical reviews, audits and investigation related to fraud waste and abuse referrals. This professional assists internal unit meetings. He/she is responsible for supporting quality improvement and medical management focused reviews, line of business focused reviews and ad hoc reviews as needed; working in collaboration with appropriate health plan departments and network providers/physicians, and providing trending, analysis and reporting of auditing data. The Coordinator plays a vital role in developing and mentoring the clinical employees of the SIU including oversight of staff performance, goal setting, and preparation of performance evaluations, and reports to the Sr. Director, Fraud & Abuse Department.

***This position may travel within Pennsylvania up to 10% of the time***

  • Assess, investigate and resolve complex issues.
  • Assesses potentially fraudulent activity by any parties against UPMC Health Plan, and implements the most effective and efficient method of investigation for each individual case.
  • Assists that all unit goals and objective are met in a timely, efficient fashion. Ensures that all SIU turn-around-times and quality measurements are met.
  • Contributes to and supports the Fraud and Abuse Training Program for all UPMC Health Plan personnel, as well as network providers and other vendors.
  • Develops and maintains the Fraud and Abuse / SIU clinical policy and procedures, and insures that all actions and investigations conform to the SIU policy and procedures
  • Encourages a positive work environment for staff members, to support the experience, skill, knowledge and capabilities of employees. Responsible to build a cohesive, professional, customer service oriented self-directed team.
  • Evaluates the work of SIU clinical personnel and completes and assists Director with performance review documentation.
  • Manages training for clinical personnel in corporate and unit procedures and investigative techniques.
  • Mentors and develops the team member's 
  • Participates in staff review
  • Participates in the development and oversight of the SIU budget.
  • Participates in the oversight of Clinical Team member's clinical audits and analysis of care and conduct clinical audits by reviewing medical record documentation and provider billing information to determine if medical record documentation supports services billed and compliance with UPMC Health Plan payment and treatment policies. Interact and follow-up with various departments including but not limited to; Medical Directors, QI, Pharmacy, Legal, and Complaint & Grievances, to assist auditors in moving the audit from inception to completion in a timely basis.
  • Performs on-site visits to providers in collaboration with Network Management when appropriate.
  • Performs reviews of clinical case files for sufficiency of content and documentation.
  • Review Clinical Auditor reports to insure they are supported by the analysis of statistical data for communication to department heads and other areas of UPMC Health Plan identifying various problem issues or trends, how they affect the Health Plan, and that make recommendations for resolution of the issue, identify training needs and or modifications to company policies and procedures.
  • Review and analyze medical records and processes related to the appropriateness of coding, clinical care, documentation, Quality of Care and health plan business rules


  • 4 years of clinical experience required
  • Fraud waste and abuse, quality review, or chart auditing experience required.
  • Candidate must be proficient in Microsoft Office, have knowledge of Commercial, Medicare, Medicaid products and ICD-9/IDC 10 and CPT-4 coding
  • Must possess a Certified Professional Coder or equivalent designation
  • Ability to interact with others in one-on-one situations to identify issues/problems and provide training/coaching to correct problem areas
  • Excellent oral and written communication skills are required
  • Strong leadership skills and abilities and strong independent decision making skills are a must
  • Must possess excellent organizational, interpersonal, and conflict management skills
  • In depth knowledge of UPMC Health Plan and different departments 
  • Formalized training / experience in Health Care Insurance Fraud preferred
  • Certification from accredited program with a concentration in Insurance Fraud/Financial Investigative Techniques, such as those offered by the AAPC, ACFE or NHCAA desired.
  • 1 year supervisory experience preferred (Experience as a Clinical Resource Specialist or Charge Nurse may be considered.)
  • This position may require the ability to travel within PA up to 10% of the time.

Licensure, Certifications, and Clearances:
  • Registered Nurse

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $29.99 to $51.22

Union Position: No

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