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. Apply tot his job Apply tot his job