| Are you an experienced nurse looking for an exciting opportunity to work in Fraud and Abuse at one of the region's leading health insurance providers? Do you have a strong knowledge of coding and auditing? We are looking for you! We are hiring a full-time Clinical Auditor/Analyst to support our Fraud, Waste & Abuse department for our location in Downtown Pittsburgh. |
This position will work daylight hours, Monday through Friday.
The Clinical Auditor/Analyst is an integral part of the Fraud, Waste & Abuse group, 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. The Clinical Auditor/Analyst creates, maintains and analyzes auditing reports related to their assigned work plan and communicates the results with management.
Other responsibilities include analysis of controlled substance prescribing and utilization to identify potential clinical care issues; prepayment review of high dollar claims, and prepayment review of unlisted codes.
You will collaborate 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 will routinely interact with members, providers, law enforcement and/or regulatory entities in the course of their duties.