Clinical Auditor Jobs
Clinical Auditor jobs are open across healthcare systems, insurance companies, government agencies, and consulting firms, from entry-level to senior and director roles, with specializations in clinical documentation, coding compliance, and quality assurance. Find a role that fits from the openings below and apply directly.
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INTRODUCTION
UPMC Health Plan has an exciting opportunity for a Clinical Auditor/Analyst position in the Fraud, Waste & Abuse department. This is a full time position working Monday through Friday daylight hours and will be a remote position.
The Clinical Auditor/Analyst is an integral part of the Special Investigations Unit (SIU) 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 but are not limited to analysis of controlled substance prescribing and utilization to identify potential clinical care issues, prepayment review of claims, and prepayment review of unlisted codes. Claims analysis and the use of fraud and abuse detection software tools will be an integral part of the function of this position. Responsibilities will involve working in collaboration 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 providers, law enforcement and/or regulatory entities in the course of their duties.
Responsibilities:
- Respond to fraud, waste, and abuse referrals and/or complete data analysis and related audits as assigned.
- Utilize fraud detection software to assess and monitor for potential FWA.
- Review and analyze claims, medical records and associated processes related to the appropriateness of coding, clinical care, documentation, and health plan business rules.
- Provide a clinical opinion for special projects or various issues including appropriate utilization of controlled substances, prescribing of controlled substances, or medically appropriate services.
- Query medical and/or pharmacy claims and conduct a risk assessment by performing data analysis and applying applicable coding guidelines, Health Plan policies and any applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD).
- Evaluate referrals from Pharmacy Benefit Manager (PBM) by analyzing medical and pharmacy claims and associated clinical documentation in HealthPlaNET, Mars, Epic and/or Cerner.
- Complete audits by utilizing standard coding guidelines and principles and coding clinics to verify that the appropriate CPT codes/DRGs were assigned and supported in the medical record documentation.
- Attend in person or virtual recipient restriction hearings.
- Review Medical Pended Queue claims to understand and resolve claim referral issues through research and interaction with other Health Plan Departments including Medical Management, Medical Directors, various committees, and other appropriate Health Plan departments.
- As necessary, assist in the development of new policies concerning future Health Plan payment of identified issue.
- Assess, investigate and resolve low to intermediate issues.
- Write concise written reports including statistical data for communication to other areas of UPMC Health Plan and to communicate with department heads for identification of various problem issues, how they affect the Health Plan, and to make recommendations for resolution of the issue.
- Identify error trends to determine appropriate training needs and suggest modifications to company policies and procedures.
- Conduct provider education, as necessary, regarding audit results.
- Communicate effectively with Medical Directors and ancillary departments as necessary to address issues and concerns.
- Understand customers including internal Health Plan Departments (i.e. Claims staff, Customer Service, Marketing, etc.) and external customers (i.e. Health System Internal Audit, Client Audit teams) to understand issues, identify solutions and facilitate resolution.
- Serve as an SIU representative at internal and external meetings, document and present findings to SIU Staff and document as appropriate in the SIU FWA Case Management Database.
- Assist in the development and revision of SIU policies and procedures.
- Identify trends for improvements internally, such as claims payment, to determine appropriate training needs and suggest modification to company policies and procedures.
- Participate in training programs to develop a thorough understanding of the materials presented.
- Obtain CPE or CEUs to maintain nursing license, and/or professional designations.
- Design and maintain reports, auditing tools and related documentation.
- Maintain or exceed designated quality and production goals.
- Maintain employee/insured confidentiality and adhere to HIPAA regulations.
BASIC QUALIFICATIONS
- Registered Nurse (RN).
- Five years of clinical experience.
- Two years of fraud & abuse, auditing, case management, quality review or chart auditing experience required.
- Ability to analyze data, maintain designated production standards, and organize multiple projects and tasks.
- In-depth knowledge of medical terminology, ICD-10 and CPT-4 coding. Knowledge of health insurance products and various lines of business.
- Detail-oriented individual with excellent organizational skills.
- Keyboard dexterity and accuracy.
- High level of oral and written communication skills.
- Proficiency with Microsoft Office products (Excel, Access, OneDrive, OneNote and Word).
Licensure, Certifications, and Clearances:
- AAPC or AHIMA Certified (CPC, CPMA, CIC, CCA, CCS, CCS-P) or AHFI designation preferred.
- Registered Nurse (RN).
- Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.
UPMC is an Equal Opportunity Employer/Disability/Veteran
INTRODUCTION
UPMC Health Plan has an exciting opportunity for a Clinical Auditor/Analyst position in the Fraud, Waste & Abuse department. This is a full time position working Monday through Friday daylight hours and will be a remote position.
The Clinical Auditor/Analyst is an integral part of the Special Investigations Unit (SIU) 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 but are not limited to analysis of controlled substance prescribing and utilization to identify potential clinical care issues, prepayment review of claims, and prepayment review of unlisted codes. Claims analysis and the use of fraud and abuse detection software tools will be an integral part of the function of this position. Responsibilities will involve working in collaboration 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 providers, law enforcement and/or regulatory entities in the course of their duties.
Responsibilities:
- Respond to fraud, waste, and abuse referrals and/or complete data analysis and related audits as assigned.
- Utilize fraud detection software to assess and monitor for potential FWA.
- Review and analyze claims, medical records and associated processes related to the appropriateness of coding, clinical care, documentation, and health plan business rules.
- Provide a clinical opinion for special projects or various issues including appropriate utilization of controlled substances, prescribing of controlled substances, or medically appropriate services.
- Query medical and/or pharmacy claims and conduct a risk assessment by performing data analysis and applying applicable coding guidelines, Health Plan policies and any applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD).
- Evaluate referrals from Pharmacy Benefit Manager (PBM) by analyzing medical and pharmacy claims and associated clinical documentation in HealthPlaNET, Mars, Epic and/or Cerner.
- Complete audits by utilizing standard coding guidelines and principles and coding clinics to verify that the appropriate CPT codes/DRGs were assigned and supported in the medical record documentation.
- Attend in person or virtual recipient restriction hearings.
- Review Medical Pended Queue claims to understand and resolve claim referral issues through research and interaction with other Health Plan Departments including Medical Management, Medical Directors, various committees, and other appropriate Health Plan departments.
- As necessary, assist in the development of new policies concerning future Health Plan payment of identified issue.
- Assess, investigate and resolve low to intermediate issues.
- Write concise written reports including statistical data for communication to other areas of UPMC Health Plan and to communicate with department heads for identification of various problem issues, how they affect the Health Plan, and to make recommendations for resolution of the issue.
- Identify error trends to determine appropriate training needs and suggest modifications to company policies and procedures.
- Conduct provider education, as necessary, regarding audit results.
- Communicate effectively with Medical Directors and ancillary departments as necessary to address issues and concerns.
- Understand customers including internal Health Plan Departments (i.e. Claims staff, Customer Service, Marketing, etc.) and external customers (i.e. Health System Internal Audit, Client Audit teams) to understand issues, identify solutions and facilitate resolution.
- Serve as an SIU representative at internal and external meetings, document and present findings to SIU Staff and document as appropriate in the SIU FWA Case Management Database.
- Assist in the development and revision of SIU policies and procedures.
- Identify trends for improvements internally, such as claims payment, to determine appropriate training needs and suggest modification to company policies and procedures.
- Participate in training programs to develop a thorough understanding of the materials presented.
- Obtain CPE or CEUs to maintain nursing license, and/or professional designations.
- Design and maintain reports, auditing tools and related documentation.
- Maintain or exceed designated quality and production goals.
- Maintain employee/insured confidentiality and adhere to HIPAA regulations.
BASIC QUALIFICATIONS
- Registered Nurse (RN).
- Five years of clinical experience.
- Two years of fraud & abuse, auditing, case management, quality review or chart auditing experience required.
- Ability to analyze data, maintain designated production standards, and organize multiple projects and tasks.
- In-depth knowledge of medical terminology, ICD-10 and CPT-4 coding. Knowledge of health insurance products and various lines of business.
- Detail-oriented individual with excellent organizational skills.
- Keyboard dexterity and accuracy.
- High level of oral and written communication skills.
- Proficiency with Microsoft Office products (Excel, Access, OneDrive, OneNote and Word).
Licensure, Certifications, and Clearances:
- AAPC or AHIMA Certified (CPC, CPMA, CIC, CCA, CCS, CCS-P) or AHFI designation preferred.
- Registered Nurse (RN).
- Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.
UPMC is an Equal Opportunity Employer/Disability/Veteran
See All 35+ Clinical Auditor Jobs
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Find Clinical Auditor JobsClinical Auditor Job Market
A snapshot from current openings nationwide, updated as new roles post.
Who's Hiring
- Molina Healthcare8
- Cotiviti4
- Neighborhood Health Plan of Rhode Island2
- Waystar2
- Abbott1
Top Industries Hiring
- Healthcare & Medical Services17
- Insurance7
- Technology & Software7
- Biotechnology & Pharmaceuticals2
- Education2
What Employers Look For
The qualifications that appear most often in clinical auditor jobs.
- Knowledge of ICD-10-CM/PCS coding guidelines and clinical documentation standards
- Experience conducting medical record audits in an acute care or managed care setting
- Certification such as CPC, RHIA, RHIT, or CCS from a recognized credentialing body
- Proficiency with electronic health record systems such as Epic, Cerner, or Meditech
- Familiarity with CMS regulations, RAC audit processes, and payer-specific requirements
- Strong written communication skills for producing clear, actionable audit reports
Tips for Your Clinical Auditor Job Search
Quantify audit findings on your resume
Hiring managers want to see impact, not just duties. List the number of charts reviewed per cycle, discrepancy rates you identified, or compliance improvements you drove. Concrete outcomes set clinical auditor resumes apart from generic healthcare compliance applications.
List your coding credentials front and center
CPC, RHIA, RHIT, and CCS credentials are often minimum requirements, not nice-to-haves. Put them in your header or a dedicated certifications section so recruiters spot them before reading a single bullet point under your work history.
Filter openings by audit specialty you know
Clinical auditor roles split sharply between coding audits, quality measure audits, and clinical documentation improvement. Target openings that match your actual specialty first, since cross-training during interviews is a harder sell than demonstrated depth in one area.
Apply early to roles that fit
Migrate Mate lists clinical auditor openings from across the United States in one place, so you can find roles that match and apply directly to each listing.
Prepare for live chart review exercises
Many clinical auditor interviews include a timed chart review or mock audit scenario. Practice pulling out primary diagnoses, flagging documentation gaps, and citing the specific guideline that applies. Knowing your ICD-10 and CMS guidelines cold is the difference in these exercises.
Negotiate scope before accepting an offer
Ask how many records you are expected to audit per week, whether audits are prospective or retrospective, and what the appeals process looks like. These details affect workload and professional risk more than title or department name.
Clinical Auditor Jobs: Frequently Asked Questions
Which companies are hiring the most clinical auditors?
The companies hiring the most clinical auditors right now include Molina Healthcare, Cotiviti, and Neighborhood Health Plan of Rhode Island, with the largest share of openings in Florida, Texas, and Pennsylvania, based on current listings on Migrate Mate as of June 2026. Health systems, managed care organizations, and revenue cycle consulting firms consistently post the highest volume of openings.
How many clinical auditor jobs are remote?
About 46% of clinical auditor openings are fully remote or hybrid as of June 2026, reflecting the role's dependence on electronic health records rather than physical chart rooms. Coding-focused and payer-side audit roles tend to offer the most remote flexibility, while facility-based quality and CDI audit positions more often require on-site presence.
How do you become a clinical auditor?
Start by building a foundation in health information management, medical coding, or clinical nursing, then earn a recognized credential such as a CPC, RHIA, or CCS. Gain hands-on experience reviewing medical records in a billing, coding, or compliance setting. From there, move into an entry-level audit role within a health system or payer, where you develop proficiency with audit methodologies, regulatory guidelines, and report writing before advancing to independent or senior audit work.
Can you get a clinical auditor job with little experience?
Yes, entry-level clinical auditor roles exist, particularly in coding audits and quality assurance support. Employers hiring candidates with limited experience typically expect a relevant credential like a CPC or RHIT in place of years on the job. Internships, externships through coding programs, or volunteer chart review work for community clinics can substitute for paid experience when you're building your first audit portfolio.
What does the clinical auditor interview process look like?
Most clinical auditor interviews include a phone or video screen focused on your coding background and audit experience, followed by a technical round where you may be asked to review a sample chart or walk through how you would handle a specific audit finding. A final round often involves meeting the compliance or HIM leadership team and discussing your familiarity with the organization's payer mix and documentation standards. Some employers also issue a written take-home audit exercise before extending an offer.
Where can I find and apply to clinical auditor jobs?
You can find and apply to clinical auditor jobs on Migrate Mate, which lists current openings from across the United States. Search the available roles, find the ones that match your specialty and experience level, and apply directly to each listing without leaving the platform.
See All 35+ Clinical Auditor Jobs
Jump back to the full list of openings and apply to any clinical auditor role that fits.
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