COVID-19 Vaccination Information

Across UPMC, our guiding principle is to always prioritize the safety of our employees, patients, and members. UPMC believes that vaccination is important, helps protect all, and advocates that everyone who can be vaccinated should be vaccinated.

UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

If you are not yet vaccinated, we urge you to get a vaccine now. You can schedule your COVID-19 vaccination through UPMC or visit a non-UPMC provider or UPMC Urgent Care location.

Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

For more information about UPMC’s response to COVID-19, please visit UPMC.com/coronavirus.

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   Current UPMC employees must apply in HR Direct

CHC RN Clinical Auditor/Analyst

  • Job ID: 282622480
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: 68172 HPLAN Medical Mgmt CHC
  • Location: 600 Grant St, Pittsburgh PA 15219
  • Union Position: No
  • Salary Range: $29.18 to $49.16 / hour

Description

UPMC Health Plan is hiring a full-time CHC Clinical Auditor/Analyst. This position will work standard daylight hours, Monday through Friday, and will work remotely. 

The CHC Clinical Auditor/Analyst is an integral part of the Clinical Affairs team collaborative approach for informing and supporting care management and service coordination holistic support of Health Plan members. The RN auditor is responsible for conducting clinical audits and reviews regarding the analysis of care and services related to clinical and service coordination guidelines, regulatory requirements, and resource utilization. The audit review includes investigation into all available medical record document platforms and determinations of care paths utilizing clinical practice guidelines and informed clinical practice. The Clinical Auditor Analyst creates, maintains and analyzes auditing reports related to their assigned work plan and communicates the results with management. The RN participates as indicated in interdisciplinary team meetings for member review.

Responsibilities:

 

  • Participate as needed in special projects and other auditing activities. Provide assistance to other departments as requested. 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.
  • Maintain or exceed designated quality and production goals.
  • Identify error trends to determine appropriate training needs and suggest modifications to company policies and procedures.
  • 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.
  • Write concise written reports including statistical data for communication to other areas of UPMC.
  • As necessary, assist in the development of new policies and procedures concerning holistic care of CHC NFCE participants
  • Provide a clinical opinion for special projects or various issues including appropriate utilization of LTSS services, or medically appropriate services.
  • Review and analyze claims, medical records and associated processes related to the appropriateness of providing LTSS Services, clinical care, documentation, and health plan business rules.
  • Conduct comprehensive record reviews that include the medical, behavioral, pharmacy, and social needs of the member.
  • Performs other duties as assigned
  • Performs in accordance with system-wide competencies/behaviors.
  • 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. Design and maintain reports, auditing, tools and related documentation.

 

Qualifications

  • Registered Nurse (RN), or Bachelor of Science in Nursing (BSN)
  • Bachelor's degree (BSN or related field) required
  • Minimum 5 years nursing experience required
  • 2 years of experience in clinical, utilization management, home care, discharge planning, or case management
  • Ability to analyze data, maintain designated production standards, and organize multiple projects and tasks.
  • Detail-oriented individual with excellent organizational skills
  • High level of oral and written communication skills
  • Proficiency with Microsoft Office products (Excel, Access, and Word)
  • Keyboard dexterity and accuracy.


Licensure, Certifications, and Clearances:

  • Registered Nurse (RN)

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct