Intermediate Clinical Auditor/Analyst, QA – Remote

UPMC Health Plan is looking for an Intermediate Clinical Auditor/Analyst to join the Quality Assurance team! This role will work standard daylight hours, Monday – Friday. The team is based out of downtown Pittsburgh’s US Steel Tower, however, this role may work remotely. 

The Intermediate Clinical Auditor/Analyst is an integral part of the Quality Assurance and Operational Integrity department 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. This includes using vast clinical knowledge to ensure correct DRG procedural and diagnosis codes have been used appropriately on claims. This role also acts as a SME for the department in representing management in meetings, training new staff and auditing peers. Collects program data to monitor/ensure compliance requirements and establishes and revises better best practice within the department. The Intermediate Clinical Auditor Analyst reviews medical records, 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 payment policies, prepayment, and post payment review of high dollar claims, and prepayment review of diagnosis and procedural codes. Responsibilities will involve working in collaboration with appropriate Health Plan departments including Quality Improvement, Claims, and Medical Directors as needed 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 detailed reports of audit findings. 

Responsibilities:

• 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 and other auditing activities.
• 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.
• Assess, investigate, and resolve complex issues. Write concise written reports 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.
• Communicate effectively with Medical Directors and ancillary departments as necessary to address issues and concerns.
• Participate as needed in special projects and other auditing activities. Provide assistance to other departments as requested.
• 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 a QA/OI Department representative at internal and external meetings, document, and present findings to QA/OI Staff.
• Assist in the development and revision of QA/OI department policies and procedures as needed.
• Perform audit peer reviews for Clinical Auditor/Analysts. Provide new-hire training to Clinical Auditor/Analysts.
• 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.