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   Current UPMC employees must apply in HR Direct

Quality Assurance Coding Specialist


UPMC Health Plan has an exciting opportunity for a full-time Qualify Assurance Coding Specialist!

With the consistent membership growth in our Medicare and ACA population, the Quality Assurance Coding Specialist Auditor will assist in conducting additional focused claims diagnosis coding reviews to ensure diagnosis codes submitted on a claim are supported with in the provider’s documentation.     

They will also assist with multiple government risk adjustment data validation audit requests received from either CMS (Medicare LOB), HHS (ACA LOB) or OIG (currently focusing on Medicare LOB).  They will review internal electronic record systems and abstracted records to submit the best medical record(s) to support the audited diagnosis codes. 

This is a dynamic position in which you get to work with a team of nurses and coders to audit and review medical records to ensure the diagnosis codes submitted to the government-supported

This position is work-from-home but could be required to come into the office for mandatory meetings! Up for the challenge? Apply today!


  • Complete reviews of focused claims diagnosis codes conducted by another Health Plan Department to ensure the diagnosis codes recommended to be redacted are not supported. 
  • Review the coding of diagnoses and verifying the proper ICD-9-CM codes were assigned by the HCC Coding Specialist.
  • Communicate effectively with Risk Adjustment Staff, nurse reviewers and physicians and ancillary departments as necessary to address issues and concerns.
  • Provide assistance to other departments as requested.
  • Completion of special projects including claims and/or coding related audit support.
  • Utilize standard coding guidelines and principles and coding clinics to verify that the appropriate ICD-9-CM and CPT codes were assigned including modifiers for correct DRG/APC assignment and accurate reimbursement.
  • Monitor the assignment of the principal and secondary diagnoses and procedures by thoroughly reviewing all documentation in the medical record utilizing knowledge of anatomy, physiology, medical terminology and pathology.
  • Ensure that all codes are documented for the assignment of a valid and accurate Hierarchical Condition Category (HCC).
  • Compile and report statistical data to internal and external customers.
  • Determine diagnoses that were treated, monitored and evaluated and procedures done during the episode of care to validate that the appropriate codes were assigned by the HCC Coding Specialist.
  • Review the discharge summary, history and physical, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room record to accurately assign a diagnosis and / or procedure.



  • Graduate of an approved Health Record Administration or Accredited Medical Record Technician program (RHIA/RHIT or eligible) or a certified coding program.
  • Five (5) years of coding experience in a health care setting required. 
  • Three (3) years of claims and/or general auditing experience preferred. 
  • Extensive knowledge of ICD-9 and CPT classifications and coding of diagnoses and procedures is required.

In-depth knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is required.

The ability to problem solve and to communicate in a professional manner with staff and other health care professionals is essential.

Excellent written and verbal communication skills are essential. Proficiency in computer skills required for coding (MARS, Cerner). Detail oriented individual with excellent organizational skills

High degree of oral and written communication skills.Proficiency in MS Office/PC skills.

Traveling may be required as necessary.

EDUCATIONAL/KNOWLEDGE PREFERENCES:Bachelors Degree or equivalent education/experience.

Licensure, Certifications, and Clearances:

  • Certified Coding Specialist (CCS) OR Certified Professional Coder (CPC) OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT)
  • Act 34

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

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