Location: Pittsburgh,PA, USA
UPMC Health Plan is looking for an Intermediate Clinical Auditor/Analyst to join the Quality Assurance team! This role will work standard daylight hours, Monday - Friday. The team is based out of downtown Pittsburgh's US Steel Tower, however, this role may work remotely.
The Intermediate Clinical Auditor/Analyst is an integral part of the Quality Assurance and Operational Integrity department 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 includes using vast clinical knowledge to ensure correct DRG procedural and diagnosis codes have been used appropriately on claims. 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 Intermediate Clinical Auditor Analyst reviews medical records, 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 payment policies, prepayment, and post payment review of high dollar claims, and prepayment review of diagnosis and procedural codes. Responsibilities will involve working in collaboration with appropriate Health Plan departments including Quality Improvement, Claims, and Medical Directors as needed 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 detailed reports of audit findings.
**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.
+ 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. **Licensure, Certifications, and Clearances:**
+ AAPC or AHIMA Certified (CPC, CPMA, CIC, CCA, CCS, CCS-P, CRC) or AHFI designation required.
+ Registered Nurse (RN)
+ Act 31 Child Abuse Reporting with renewal
+ Act 33 with renewal
+ Act 34 with renewal
+ Act 73 FBI Clearance with renewal
*Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.
**UPMC is an Equal Opportunity Employer/Disability/Veteran**