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   Current UPMC employees must apply in HR Direct

Clinical Auditor/Analyst (Registered Nurse) - Quality Assurance & Operational Integrity

Description

Are you an experienced nurse looking for an exciting opportunity to work in Quality Review at one of the region's leading health insurance providers? Do you have a strong knowledge of coding and auditing? Are you looking for a chance to offer your clinical expertise to a team primarily comprised of coders? We are looking for you! UPMC Health Plan is hiring a full-time Clinical Auditor/Analyst to support our Quality Assurance and Operational Integrity department for our location in Downtown Pittsburgh. 

This position will predominantly work from home, standard daylight hours, Monday through Friday. 

This position will be an integral part of the Quality Assurance and Operational Integrity department and will be responsible for conducting clinical audits and reviews regarding the analysis of care and services related to clinical guidelines, coding requirements, regulatory requirements, and resource utilization. You will use your vast clinical knowledge to ensure correct DRG procedural and diagnosis codes have been used appropriately on claims. The Clinical Auditor/Analyst will review medical records and create, maintain and analyze auditing reports related to their assigned work plan and communicate the results with management. 

Other responsibilities include analysis of payment policies, prepayment review of high dollar claims, and prepayment review of unlisted codes. 
You will collaborate with appropriate Health Plan departments including Quality Improvement, Legal, and Claims to facilitate the resolution of issue or cases. Responsibilities may involve multiple line of business-focused reviews, or ad hoc reviews as needed; analysis of billing by providers/physicians, and providing trending, analysis and reporting of auditing data.

 


.The Clinical Auditor/Analyst is an integral part of the Fraud & Abuse unit, and is responsible for conducting clinical audits and reviews regarding the analysis of care and services related to clinical guidelines, coding requirements, regulatory requirements, and resource utilization. The Clinical Auditor Analyst creates, maintains and analyzes auditing reports related to their assigned work plan and communicates the results with management. Other responsibilities include, but are not limited to: analysis of controlled substance prescribing and utilization to identify potential clinical care issues; prepayment review of high dollar claims, and prepayment review of unlisted codes. Claims analysis and the use of fraud and abuse detection software tools will be an integral part of the function of this position. Responsibilities will involve working in collaboration with appropriate Health Plan departments including Quality Improvement, Legal, and Medical Management to facilitate the resolution of issue or cases. Responsibilities may involve multiple line of business focused reviews, or ad hoc reviews as needed; analysis of billing by providers/physicians, and providing trending, analysis and reporting of auditing data. The Clinical Auditor/Analyst will routinely interact with members, providers, law enforcement and/or regulatory entities in the course of their duties.

Responsibilities:

 

  • Design and maintain reports, auditing, tools and related documentation.
  • Conduct provider education, as necessary, regarding audit results.
  • Understand customers including internal Health Plan Departments (i.e. claims staff, customer service, Marketing, etc.) and external customers (i.e. Health System Internal Audit, Client Audit teams) To understand issues, identify solutions and facilitate resolution.
  • Assess, investigate and resolve complex issues. Write concise written reports including statistical data for communication to other areas of UPMC Health Plan and to communicate with department heads for identification of various problem issues, how they affect the Health Plan, and to make recommendations for resolution of the issue. Identify error trends to determine appropriate training needs and suggest modifications to company policies and procedures.
  • Participate as needed in special projects and other auditing activities. Provide assistance to other departments as requested.
  • Maintain or exceed designated quality and production goals.
  • Participate in training programs to develop a thorough understanding of the materials presented. Obtain CPE or CEUs to maintain nursing license, and/or professional designations.
  • Serve as a QA Department representative at internal and external meetings, document and present findings to QA Staff.
  • Identify trends for improvements internally, such as claims payment, to determine appropriate training needs and suggest modification to company polices and procedures.
  • Review and analyze claims, medical records and associated processes related to the appropriateness of coding, clinical care, documentation, and health plan business rules.
  • Review Medical Pended Queue claims to understand and resolve claim referral issues through research and interaction with other Health Plan Departments including Medical Management, Medical Directors, various committees, and other appropriate Health Plan departments. As necessary, assist in the development of new policies concerning future Health Plan payment of identified issue.
  • Assist in the development and revision of Fraud & Abuse department policies and procedures.
  • Provide a clinical opinion for special projects or various issues including appropriate utilization of controlled substances, prescribing of controlled substances, or medically appropriate services.
  • Respond to fraud, waste, and abuse referrals and/or complete data analysis and related audits as assigned.

 

Qualifications

  • Registered Nurse (RN), or Bachelor of Science in Nursing (BSN).
  • Five years of clinical experience.
  • Two years of case management, fraud & abuse, auditing, quality review or chart auditing experience required.
  • Ability to analyze data, maintain designated production standards, and organize multiple projects and tasks.
  • In-depth knowledge of medical terminology, ICD-10 and CPT-4 coding
  • Knowledge of health insurance products and various lines of business.
  • Detail-oriented individual with excellent organizational skills.
  • Keyboard dexterity and accuracy.
  • High level of oral and written communication skills
  • Proficiency with Microsoft Office products (Excel, Access, and Word).
  • Experience with HCC/Risk Adjustment coding  preferred. 
  • Experience with DRG Assignment and clinical validation of diagnoses preferred. 
  • Proficiency using Epic, One Content and/or Power Chart preferred.


Licensure, Certifications, and Clearances:

  • CPC Designation preferred
  • Registered Nurse (RN)

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