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   Current UPMC employees must apply in HR Direct

Fraud and Abuse Specialist (Coder)

  • Job ID: 103244615
  • 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: $23.75 to $41.09 / hour

Description

Purpose:
UPMC Health Plan's Fraud, Waste & Abuse Department is seeking an individual with Coding experience to manage their pre-payment hold. 

The Fraud and Abuse Specialist investigates all allegations of health care fraud and/or abuse against UPMC Health Plan. Candidates who have their CPC along with experience with outpatient/medical coding will be preferred. 

Considering candidates from all regions as Work-from-home is an option to employees. 

Responsibilities:
  • Perform investigations and/or audits resulting from fraud and abuse (F&A) referrals. Reviews include, but are not limited to, providers and vendors regarding business issues such as claims, marketing, underwriting, and other circumstances of suspected F&A which, upon investigation, give evidence that a violation may have occurred.
  • Maintain database of investigative activity that should include names, addresses, identifying information regarding all parties in the investigation, and the documents in the file.
  • Act as a liaison with key internal contacts in the investigation and prosecution of insurance F&A.
  • Testify in a court of law as needed and participate in coordinating subrogation, reimbursement, and restitution matters.
  • Act as a liaison with the DPW, BPI, CMS, PID, the IFPA, local, county, state, and federal law enforcement agencies, and all other relevant regulatory oversight agencies,
  • Maintain investigation files of evidence collected or received including claims, check in payment of claims, and other documents submitted in support of alleged fraud.

Qualifications

  • Bachelor's degree in a related field (or equivalent years of experience) required.
  • Three (3) years of experience in health insurance, preferably in a fraud and abuse investigative capacity required.
  • Experience should include claims processing, coding, auditing, underwriting, and/or information systems.

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct

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