Intermediate Clinical Auditor/Analyst, QA - Remote

$68,578 - $115,752/Yr

University of Pittsburgh Medical Center - Pittsburgh, PA

Full-time - Mid Level

Remote - Pittsburgh, PA

Hospitals

About the position

The Intermediate Clinical Auditor/Analyst plays a crucial role in the Quality Assurance and Operational Integrity department at UPMC Health Plan. This position involves conducting clinical audits and reviews to ensure compliance with clinical guidelines, coding requirements, and regulatory standards. The auditor will utilize their clinical expertise to analyze claims and medical records, ensuring accurate coding and documentation while also serving as a subject matter expert within the department.

Responsibilities

• Review and analyze claims, medical records and associated processes related to the appropriateness of coding, clinical care, documentation, and health plan business rules.
• Provide a clinical opinion for special projects and other auditing activities.
• Complete audits by utilizing standard coding guidelines and principles and coding clinics to verify that the appropriate CPT codes/DRGs were assigned and supported in the medical record documentation.
• Assess, investigate, and resolve complex issues. Write concise written reports 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.
• Communicate effectively with Medical Directors and ancillary departments as necessary to address issues and concerns.
• Participate as needed in special projects and other auditing activities. Provide assistance to other departments as requested.
• 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.
• Serve as a QA/OI Department representative at internal and external meetings, document, and present findings to QA/OI Staff.
• Assist in the development and revision of QA/OI department policies and procedures as needed.
• Perform audit peer reviews for Clinical Auditor/Analysts. Provide new-hire training to Clinical Auditor/Analysts.
• 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.
• Design and maintain reports, auditing tools and related documentation.
• Maintain or exceed designated quality and production goals. Maintain employee/insured confidentiality.

Requirements

• Registered Nurse (RN).
• Bachelor of Science in Nursing (BSN) or the equivalent combination of education, professional training, and work experience.
• Five years of clinical experience.
• Three years of fraud & abuse, auditing, case management, quality review or chart auditing experience required.
• DRG or APR experience highly preferred.
• 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, OneDrive, OneNote, and Word).
• Experience with DRG Assignment and clinical validation of diagnoses.
• Experience with HCC/Risk Adjustment coding preferred.
• Proficiency using Epic, One Content and/or Power Chart preferred.

Nice-to-haves

• Experience with HCC/Risk Adjustment coding preferred.
• Proficiency using Epic, One Content and/or Power Chart preferred.