Clinical Auditor/Analyst Intermediate - Remote

UPMC is a world-renowned, nonprofit health care provider and insurer committed to delivering exceptional, people-centered care and community services. Headquartered in Pittsburgh and affiliated with the University of Pittsburgh Schools of the Health Sciences, UPMC is shaping the future of health through clinical and technological innovation, research, and education. Dedicated to advancing the well-being of our diverse communities, we provide nearly $2 billion annually in community benefits, more than any other health system in Pennsylvania. Our 100,000 employees — including more than 5,000 physicians — care for patients across more than 40 hospitals and 800 outpatient sites in Pennsylvania, New York, and Maryland, as well as overseas. UPMC Insurance Services covers more than 4 million members, providing the highest-quality care at the most affordable price.

The Clinical Auditor/Analyst Intermediate is an integral part of the Special Investigations Unit (SIU) 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. This role also acts as a SME for the department in representing management in meetings, training new staff and auditing peers. Collects program data to monitor/ensure compliance requirements and establishes and revises better best practice within the department. The Clinical Auditor/Analyst Intermediate 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 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 Intermediate will routinely interact with providers, law enforcement and/or regulatory entities in the course of their duties.

Respond to fraud, waste, and abuse referrals and/or complete data analysis and related audits as assigned. Utilize fraud detection software to assess and monitor for potential FWA. 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 or various issues including appropriate utilization of controlled substances, prescribing of controlled substances, or medically appropriate services. Query medical and/or pharmacy claims and conduct a risk assessment by performing data analysis and applying applicable coding guidelines, Health Plan policies and any applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD). Evaluate referrals from Pharmacy Benefit Manager (PBM) by analyzing medical and pharmacy claims and associated clinical documentation in HealthPlaNET, Mars, Epic and/or Cerner. 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. Attend in person or virtual recipient restriction hearings. 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. 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. Conduct provider education, as necessary, regarding audit results. 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 an SIU representative at internal and external meetings, document and present findings to SIU Staff and document as appropriate in the SIU FWA Case Management Database. Assist in the development and revision of SIU policies and procedures. Identify trends for improvements internally, such as claims payment, to determine appropriate training needs and suggest modification to company policies and procedures. Perform audit peer reviews for Clinical Auditor/Analysts. Provide new-hire training to Clinical Auditor/Analysts. Performing administrative appeals/preparing medical necessity appeals for Medical Directors for second level appeals. 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.