Job Description

Job Title: Manager, Clinical Investigations - Fraud, Waste & Abuse
Job ID: 79974850
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: Fraud, Waste & Abuse
Location: 600 Grant St, Pittsburgh PA 15219


Are you an experienced nurse in the field of fraud, waste, and abuse, quality review, or chart auditing? Are you looking for a unique opportunity to expand on your skillset to lead and mentor others? Consider this fantastic new opening on our team!

UPMC Health Plan is hiring a full-time Manager, Clinical Investigations to support our Fraud, Waste and Abuse Department for our location in Downtown Pittsburgh. This position will work standard daylight hours, Monday through Friday.

The Manager, Clinical Investigations is responsible for directing the clinical staff assigned to perform clinical reviews, audits and investigation related to fraud and abuse referrals. You will be responsible for supervision and maintenance of the fraud and abuse specialized software tool, databases, compliance matrices, and other unit reporting as it relates to clinical audits.

This professional leads internal unit meetings, and represents the Special Investigations Unit at other interdepartmental meetings and at meetings external to the Health Plan. You will also be responsible for providing trending, analysis and reporting of referrals and investigative data and the compilation of reports resulting from clinical reviews. You will hold responsibility for creation and revision of the Special Investigation Units clinical policies and procedures and education program, and serve as a process expert for fraud and abuse clinical investigations and associated financial recoveries.

Other responsibilities include, but are not limited to; 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 Manager directly manages the clinical employees of the SIU including oversight of staff performance, goal setting, and preparation of performance evaluations, and reports to the Sr. Manager, Clinical Audits.


  • Contributes to the Fraud and Abuse / SIU clinical policy and procedures, and insures that all actions and investigations conform to the SIU policy and procedures.
  • Manages training for clinical personnel in corporate and unit procedures and investigative techniques.
  • Performs on-site visits to providers in collaboration with Network Management when appropriate
  • Contributes to and supports the Fraud and Abuse Training Program for all UPMC Health Plan personnel, as well as network providers and other vendors.
  • Represents the SIU in a court of law as required when approved by the department director, the Health Plan Legal Services and Compliance
  • Conduct 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.
  • Represents the Special Investigations Unit (SIU) at internal and external meetings.
  • Review and analyze medical records and processes related to the appropriateness of coding, clinical care, documentation, Quality of Care and health plan business rules
  • Assess, investigate and resolve complex issues.
  • Manages the detection of potentially fraudulent activity by any parties against UPMC Health Plan, and implements the most effective and efficient method of investigation for each individual case
  • 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.


  • 4 years of clinical experience, and, fraud waste and abuse, quality review, or chart auditing experience are required.
  • Minimum of 2 years of supervisor experience (in a health care, insurance, or SIU setting preferred).
  • Experience as a Clinical Resource Specialist or Charge Nurse may be considered.
  • BSN required.
  • Excellent oral and written communication skills are required.
  • Strong leadership skills and abilities and strong independent decision making skills are a must.
  • Expert process and project management, negotiation, and analytical skills are required.
  • Must possess excellent organizational, interpersonal, and conflict management skills.
  • 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 (CPC) or equivalent designation.
  • In depth knowledge of UPMC Health Plan and different departments.
  • Preferred: 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.

Licensure, Certifications, and Clearances:

  • Registered Nurse (RN) 

UPMC is an Equal Opportunity Employer/Disability/Veteran


Salary Range: $38.15 to $64.63 / hour

Union Position: No

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