The Healthcare Compliance Auditor Senior I plays a key role in supporting UPMC's compliance and regulatory oversight activities through the identification, assessment, and mitigation of healthcare compliance risks. Leveraging expertise in healthcare operations, reimbursement methodologies, and regulatory requirements, this position conducts auditing and monitoring activities and collaborates with clinical, operational, revenue cycle, and compliance stakeholders to promote adherence to regulatory requirements. This is a full-time position that works Monday through Friday during normal business hours. The role follows a hybrid work model, with a combination of remote work and on-site attendance at UPMC's USX office.
If this sounds like the role for you, apply today!
Responsibilities:
- Must have knowledge of medical terminology, HIM coding, and reimbursement methodologies.
- Has working knowledge of internal policies and external regulatory requirements (e.g., Medicare, Medicaid, DOH, and other applicable authorities).
- Conducts independent research on Medicare, Medicaid, and other regulatory requirements impacting billing and compliance.
- Understands patient flow and care in a clinical setting, healthcare billing and healthcare compliance issues.
- Reviews clinical documentation, coding, billing, and reimbursement practices to identify potential compliance risks and opportunities for improvement.
- Monitors and validates the implementation of corrective actions to ensure sustained compliance.
- Conducts follow-up reviews to validate the effectiveness and sustainability of corrective action plans.
- Collaborates with clinical, operational, revenue cycle, and compliance stakeholders to evaluate processes and ensure adherence to regulatory requirements and organizational standards.
- Supports compliance risk assessments and reviews, as assigned.
- Maintains detailed audit workpapers and supporting documentation in accordance with departmental standards.
- Develops and delivers compliance education and training related to audit findings.
- Monitors regulatory updates and industry guidance to identify emerging risks and assess organizational impact.
- Interprets and applies federal and state healthcare regulations, payer requirements, coding guidelines, and organizational policies to audit activities.
- Maintains effective verbal and written communication skills with the ability to engage stakeholders across all organizational levels.
- Contributes to the department’s reputation through high-quality work, collaboration, and adherence to compliance principles.
- Bachelor's degree or equivalent clinical certification and Three (3) years of progressive clinical, audit, or compliance experience
- OR High School Diploma/GED and Seven (7) years of related work experience.
- Demonstrated expertise in healthcare operations
- Strong executive communication and influence skills
- Prior experience within Revenue Cycle preferred
- Experience with utilization review preferred
- Prior experience with clinical operations preferred
- Superior computer skills, including experience in MS Office tools: Word, Excel, Outlook PowerPoint, CoPilot and SharePoint
- Strong understanding of risk analysis and process improvement
- Willingness to travel, as needed to UPMC facilities within the tri state area
Licensure, Certifications, and Clearances: - Act 34
- Relevant professional license is required (RN/LPN or equivalent).
- Relevant professional certification is preferred. (Six Sigma, Certification in Health Care Compliance (CHC), billing or coding certificate, Clinical Documentation Improvement Specialists (CDI) all others will be considered)
UPMC is an Equal Opportunity Employer/Disability/Veteran