COVID-19 Vaccination Information

Across UPMC, our guiding principle is to always prioritize the safety of our employees, patients, and members. UPMC believes that vaccination is important, helps protect all, and advocates that everyone who can be vaccinated should be vaccinated.

UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

If you are not yet vaccinated, we urge you to get a vaccine now. You can schedule your COVID-19 vaccination through UPMC or visit a non-UPMC provider or UPMC Urgent Care location.

Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

For more information about UPMC’s response to COVID-19, please visit UPMC.com/coronavirus.

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   Current UPMC employees must apply in HR Direct

Fraud, Waste and Abuse Investigator I (Remote)

  • Job ID: 545362952
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: Fraud, Waste & Abuse
  • Location: 600 Grant St, Pittsburgh PA 15219
  • Union Position: No
  • Salary Range: $24.78 to $42.84 / hour

Description

UPMC Health Plan is seeking a Fraud, Waste and Abuse Investigator I to join our team!

Under the direction of the manager, The Fraud, Waste and Abuse (FWA) Investigator I is responsible for investigating assigned FWA cases, as well as researching and analyzing claims data in order to identify potential FWA. The FWA Investigator I is also responsible for maintaining the FWA case system with accurate and detailed investigative activities related to assigned cases. 

Preferences:

  • Managed care/ insurance experience.
  • Claims processing experience.
  • Microsoft Office Expertise
  • SIU experience 

This is a work-from-home position.
 

Responsibilities:

  • Investigative actions include member/provider outreach, financial tracking, prepay claims review, adhering to compliance regulations, and making healthcare oversight referrals.
  • Plan, organize and execute investigations or audits utilizing document review, witness interviews, and data analysis to identify, evaluate and measure potential healthcare fraud and abuse to determine valid cases for appropriate action.
  • Risk Assessments on FWA trends using fraud detection software and/or as assigned by Manager.
  • Oversight or assistance with the Medicaid Recipient Restriction program.
  • Present FWA trainings to internal staff.
  • Assist with the FWA hotline and referral intake.
  • Perform chart reviews to assess compliance with coding and billing regulations. Utilize standard coding guidelines, principles, and coding clinics to monitor the appropriate ICD and CPT codes for all record types to ensure accurate reimbursement.
  • Document and track activity in an internal database, provide case updates on the progress of the investigation and coordinate with management recommendations and further actions and/or resolutions.
  • Conduct detailed research to identify and apply appropriate regulatory, contractual, and industry requirements to the different benefits and products within investigations.
  • Maintain or exceed designated quality and production goals.
  • Understand and adhere to HIPAA privacy requirements.
  • Perform special projects as assigned by Management.

This is a work-from-home position.

Qualifications

  • Bachelor's Degree or equivalency and/or 2-4 years of experience in lieu of a degree. 
  • 2-4 years of related experience in investigations, claims, medical coding, auditing, or compliance or analyst, data reporting, risk management and/or data analysis required.
  • Experience in Healthcare, Law Enforcement, Insurance and Risk Management preferred.
  • The ability to problem solve and communicate professionally.
  • Detail-oriented individual with excellent organizational skills.
  • High degree of oral and written communication skills.
  • Proficiency in MS Office/PC skills including Microsoft Excel and Word.
  • Experience conducting investigations within a healthcare environment preferred.
  • Knowledge of CPT and ICD-10 coding of procedures and diagnosis is preferred.
  • Knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is preferred.


Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct

Security Alert

We are aware of scams targeting UPMC and other large companies that involve individuals posing as employees to illegitimately conduct interviews and extend false employment offers and payments to gain access to candidates' personal information. Please note that UPMC will not communicate with candidates through third-party email services like Gmail or Yahoo. While some interviews may take place via a video conferencing service, UPMC Talent Acquisition will not conduct interviews via Skype or Google Hangouts. UPMC will never ask for or disburse funds during the recruitment process. If you are hired into a role with a sign-on bonus or similar incentive, funds will be paid to you by UPMC after your start date.

If you suspect you have been a victim of a fraudulent UPMC job offer, please report the attempt using this form.