Intermediate Clinical Auditor/Analyst, QA – Remote

About the position

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.