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 at UPMC Health Plan plays a crucial role in the Quality Assurance and Operational Integrity department. This position involves conducting clinical audits and reviews to ensure compliance with clinical guidelines, coding requirements, and resource utilization. The auditor will utilize their clinical knowledge to verify the accuracy of DRG procedural and diagnosis codes on claims, while also serving as a subject matter expert (SME) in departmental meetings and training new staff. The role requires collaboration with various Health Plan departments to resolve issues and improve best practices.

Responsibilities

• Review and analyze claims, medical records, and associated processes related to coding and clinical care.
• Provide clinical opinions for special projects and auditing activities.
• Complete audits using standard coding guidelines to verify appropriate CPT codes/DRGs.
• Assess, investigate, and resolve complex issues.
• Write concise reports to communicate findings to other areas of UPMC Health Plan.
• Communicate effectively with Medical Directors and ancillary departments.
• Participate in special projects and other auditing activities as needed.
• Assist other departments as requested.
• Understand internal and external customer issues to identify solutions.
• Serve as a QA/OI Department representative at meetings and present findings.
• Assist in developing and revising QA/OI department policies and procedures.
• Perform audit peer reviews for Clinical Auditor/Analysts.
• Provide new-hire training to Clinical Auditor/Analysts.
• Design and maintain reports and auditing tools.

Requirements

• Registered Nurse (RN) with a Bachelor of Science in Nursing (BSN) or equivalent education and experience.
• Five years of clinical experience.
• Three years of fraud & abuse, auditing, case management, quality review, or chart auditing experience.
• In-depth knowledge of medical terminology, ICD-10, and CPT-4 coding.
• Detail-oriented with excellent organizational skills.
• High level of oral and written communication skills.
• Proficiency with Microsoft Office products (Excel, Access, OneDrive, OneNote, Word).
• Experience with DRG Assignment and clinical validation of diagnoses.
• Licensure and certifications such as AAPC or AHIMA Certified (CPC, CPMA, CIC, CCA, CCS, CCS-P, CRC) required.

Nice-to-haves

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

Benefits

• Full-time position with competitive hourly wage.
• Remote work flexibility.
• Opportunities for professional development and training.