Job Description

Job Title: Clinical Fraud&Abuse Auditor
Job ID: 670688
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: CCBH Fraud, Waste&Abuse
Location: 600 Grant St, Pittsburgh PA 15219

Description

Purpose:
UPMC Health Plan is hiring a Clinical Fraud & Abuse Auditor to support its Fraud & Abuse Department. In this role, you will create, maintain, and analyze audit findings, and communicate the results with the manager and director. Claims analysis and the use of fraud and abuse detection tools will be an integral part of this position. The Clinical Auditor is expected to respond to internal and external referrals, as well as complete assigned routine and random audits all within assigned time frames. This position is responsible for appropriate provider communication related to audit processes and results.

The position assists the Manager and Director in identifying trends related to potential inappropriate submission of claims by participating providers. You will participate with the other team members in developing tools to enhance the efficiency and the quality of performance within the department. Interfacing with providers regarding compliance with all federal, state, county, and contractual regulations and obligations is also a function of this position. This interfacing may include performing provider education post-audit, or as requested by department management.The clinical auditor is an integral part of the Fraud & Abuse unit, and is expected to respond to internal and external referrals, as well as complete assigned routine and random audits all within assigned time frames. This position is responsible for appropriate provider communication related to audit processes and results.


Responsibilities:
  • Complete audits or other assigned work within clearly specified time frames. -
  • Identify trends and possible concerns related to potential inappropriate submission of claims by participating providers.
  • Maintain cases in department database, and utilize auditing tools effectively.
  • Maintain confidentiality of all provider and member sensitive information reviewed during the auditing process.
  • Occasional independent travel to various provider locations in Carbon, Monroe and Pike locations as assigned, with limited overnight stays required. OR North Central Pennsylvania locations as assigned, with limited overnight stays required.
  • Participate in selected all training programs in order to develop a thorough understanding of the materials presented to the claims and service staff.
  • Provide assistance to other departments as requested by management.
  • Represent the Fraud, Waste and Abuse Department during internal workgroups, special projects, or additional meetings when requested to do so by management.
  • Responsible for interfacing with providers regarding compliance with all federal, state, county, and contractual regulations and obligations.
  • Review and analyze claims and associated medical records and processes related to the appropriateness of coding, clinical care, documentation, and health care regulations.

Qualifications

-Bachelors degree in a Health Care related field with a minimum of five years experience within a behavioral health setting.

-Two to four years of case/care management, provider chart quality reviews, or performing fraud, waste and abuse reviews within a behavioral health care setting.

-Knowledge of behavioral health Medicaid programs and services within the state of Pennsylvania.

-Ability to analyze data, meet designated production standards, and organize multiple projects and tasks.

 -In-depth knowledge of behavioral health terminology.

-Independent problem solving based on advanced-level knowledge of the service delivery system and applicable state regulations.

-General knowledge of best practices in behavioral health, emphasizing work with special needs or priority populations and in public sector systems.

 -General knowledge of managed care functional areas, including terms and definitions.

-Excellent oral and written communication skills.

-Keyboard dexterity and accuracy.

 -Proficiency with Microsoft Office products (Excel, Access, and Word).

- Must have reliable transportation and maintain ability to travel independently.

Licensure, Certifications, and Clearances:

  • Clinical Social Worker or Licensed Professional Counselor or Licensed Social Worker or Psychologist or Registered Nurse

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

Salary Range: $22.60 to $39.11

Union Position: No

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