Healthcare Compliance Auditor, Senior I

This position supports UPMC's compliance and regulatory oversight activities by identifying, assessing, and mitigating healthcare compliance risks. The role conducts auditing and monitoring activities and collaborates with clinical, operational, revenue cycle, and compliance stakeholders to ensure adherence to regulatory requirements.

Responsibilities

• Apply knowledge of medical terminology, HIM coding, and reimbursement methodologies.
• Utilize working knowledge of internal policies and external regulatory requirements (e.g., Medicare, Medicaid, DOH, and other applicable authorities).
• Conduct independent research on Medicare, Medicaid, and other regulatory requirements impacting billing and compliance.
• Understand patient flow, care in a clinical setting, healthcare billing, and compliance issues.
• Review clinical documentation, coding, billing, and reimbursement practices to identify potential compliance risks and opportunities for improvement.
• Monitor and validate the implementation of corrective actions to ensure sustained compliance.
• Conduct follow-up reviews to validate the effectiveness and sustainability of corrective action plans.
• Collaborate with clinical, operational, revenue cycle, and compliance stakeholders to evaluate processes and ensure adherence to regulatory requirements and organizational standards.
• Support compliance risk assessments and reviews, as assigned.
• Maintain detailed audit workpapers and supporting documentation in accordance with departmental standards.
• Develop and deliver compliance education and training related to audit findings.
• Monitor regulatory updates and industry guidance to identify emerging risks and assess organizational impact.
• Interpret and apply federal and state healthcare regulations, payer requirements, coding guidelines, and organizational policies to audit activities.
• Maintain effective verbal and written communication skills to engage stakeholders across all organizational levels.
• Contribute to the department’s reputation through high-quality work, collaboration, and adherence to compliance principles.

Requirements

• 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.

Qualifications

• Act 34 clearance.
• Relevant professional license is required (RN/LPN or equivalent).
• Relevant professional certification is preferred (e.g., Six Sigma, Certification in Health Care Compliance (CHC), billing or coding certificate, Clinical Documentation Improvement Specialists (CDI)).

Schedule

• Full-time, Monday through Friday during normal business hours.
• Hybrid work model: combination of remote work and on-site attendance at UPMC's USX office.