H-1B Visa Clinical Auditor Jobs
Clinical Auditor roles qualify as H-1B specialty occupations because they require at least a bachelor's degree in healthcare administration, nursing, or a related clinical field. Employers in hospital systems, managed care organizations, and revenue cycle firms regularly sponsor H-1B petitions for this role, making it a viable path for international professionals with auditing credentials.
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Get Access To All JobsINTRODUCTION
UPMC Health Plan is hiring a full-time Clinical Auditor/Analyst Intermediate position to support the Fraud, Waste & Abuse team. This is a full-time position working Monday through Friday daylight hours and will be remote.
ROLE AND RESPONSIBILITIES
The Clinical Auditor/Analyst Intermediate 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. This role also acts as a SME for the department in representing management in meetings, training new staff, and auditing peers. Collects program data to monitor/ensure compliance requirements and establishes and revises better best practices within the department.
The Clinical Auditor/Analyst Intermediate 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 issues 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 Intermediate 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 issues.
- Assess, investigate, and resolve complex 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.
- Participate as needed in special projects and other auditing activities.
- Provide assistance to other departments as requested.
- 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 modifications to company policies and procedures.
- Perform audit peer reviews for Clinical Auditor/Analysts.
- Provide new-hire training to Clinical Auditor/Analysts.
- Performing administrative appeals/preparing medical necessity appeals for Medical Directors for second-level appeals.
- 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.
BASIC QUALIFICATIONS
- Registered Nurse (RN).
- Bachelor of Science in Nursing (BSN) or the equivalent combination of education, professional training, and work experience.
- Five years of clinical experience.
- Three years of fraud & abuse, auditing, case management, quality review, or chart auditing experience required.
- Inpatient coding experience highly preferred.
- 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 required.
- Registered Nurse (RN)
- Act 31 Child Abuse Reporting with renewal
- Act 33 with renewal
- Act 34 with renewal
- Act 73 FBI Clearance with renewal
- 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 is hiring a full-time Clinical Auditor/Analyst Intermediate position to support the Fraud, Waste & Abuse team. This is a full-time position working Monday through Friday daylight hours and will be remote.
ROLE AND RESPONSIBILITIES
The Clinical Auditor/Analyst Intermediate 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. This role also acts as a SME for the department in representing management in meetings, training new staff, and auditing peers. Collects program data to monitor/ensure compliance requirements and establishes and revises better best practices within the department.
The Clinical Auditor/Analyst Intermediate 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 issues 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 Intermediate 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 issues.
- Assess, investigate, and resolve complex 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.
- Participate as needed in special projects and other auditing activities.
- Provide assistance to other departments as requested.
- 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 modifications to company policies and procedures.
- Perform audit peer reviews for Clinical Auditor/Analysts.
- Provide new-hire training to Clinical Auditor/Analysts.
- Performing administrative appeals/preparing medical necessity appeals for Medical Directors for second-level appeals.
- 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.
BASIC QUALIFICATIONS
- Registered Nurse (RN).
- Bachelor of Science in Nursing (BSN) or the equivalent combination of education, professional training, and work experience.
- Five years of clinical experience.
- Three years of fraud & abuse, auditing, case management, quality review, or chart auditing experience required.
- Inpatient coding experience highly preferred.
- 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 required.
- Registered Nurse (RN)
- Act 31 Child Abuse Reporting with renewal
- Act 33 with renewal
- Act 34 with renewal
- Act 73 FBI Clearance with renewal
- 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 Clinical Auditor jobs
Sign up for free to unlock all listings, filter by visa type, and get alerts for new Clinical Auditor roles.
Get Access To All JobsTips for Finding H-1B Visa Sponsorship as a Clinical Auditor
Align your credentials to specialty occupation standards
USCIS requires your degree to directly relate to clinical auditing duties. A nursing degree, health information management credential, or clinical coding certification strengthens the specialty occupation argument your employer must make in the H-1B petition.
Target revenue cycle and managed care employers
Hospital systems, health insurance companies, and revenue cycle outsourcing firms file H-1B petitions for Clinical Auditors far more regularly than small practices. Filter your search by employer type before applying to avoid wasting time on non-sponsoring organizations.
Verify prevailing wage before negotiating your offer
Your employer's LCA must certify a wage at or above the DOL prevailing wage for Clinical Auditor roles in your work location. Run the OFLC Wage Search by SOC code and metro area before any salary discussion so you know the floor.
Search LCA filing history on Migrate Mate
Pull employer LCA records on Migrate Mate to see which organizations have filed for Clinical Auditor or related healthcare auditing roles. Targeting employers with verified filing history cuts your sponsorship risk before you invest time in the application process.
Clarify coding credential requirements during screening
Many employers require CPC, CCS, or RHIA credentials alongside the degree for H-1B specialty occupation evidence. Ask directly whether the role requires a specific coding or auditing certification, since gaps here can trigger a USCIS Request for Evidence after filing.
Confirm the employer's fiscal year H-1B timeline early
USCIS opens H-1B registration in March for an October 1 start date. If you receive an offer in June, your employer must decide whether to file in the next cycle or use cap-exempt status if they qualify. Clarify this before accepting.
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Find Clinical Auditor JobsClinical Auditor H-1B Visa: Frequently Asked Questions
Does a Clinical Auditor role qualify as an H-1B specialty occupation?
Yes. Clinical Auditor positions typically qualify because they require a bachelor's degree or higher in a specific field such as health information management, nursing, or healthcare administration. USCIS evaluates whether the role normally requires a degree in a directly related discipline, and most full-scope clinical auditing positions in hospital or managed care settings meet that standard.
Which employers sponsor H-1B visas for Clinical Auditors?
Hospital networks, managed care organizations, Medicare Advantage plans, and revenue cycle management firms are the most consistent H-1B sponsors for Clinical Auditor roles. Academic medical centers also sponsor regularly and are often cap-exempt, meaning they can file outside the April lottery window. Use Migrate Mate to browse verified LCA filing history by employer before applying.
How does the H-1B prevailing wage apply to Clinical Auditor positions?
Before filing your H-1B petition, your employer must submit a Labor Condition Application certifying your offered wage meets or exceeds the DOL prevailing wage for the Clinical Auditor occupation in your specific work location. Wages are tiered by experience level, so a Level I wage applies to entry-level audit roles while Level III or IV applies to senior positions. You can verify the applicable wage using the OFLC Wage Search.
Can clinical coding certifications strengthen an H-1B petition for this role?
Yes. Credentials like the CPC, CCS, or RHIA support the specialty occupation argument by demonstrating that the role requires specialized theoretical and practical knowledge beyond a general degree. If your employer lists a coding certification as a job requirement, including it in the petition documentation reduces the likelihood of a USCIS Request for Evidence challenging whether the position is truly a specialty occupation.
What happens to my H-1B status if my Clinical Auditor role is reclassified or restructured by my employer?
A material change in your job duties, location, or employment terms requires your employer to file an amended H-1B petition with USCIS before the change takes effect. If your role shifts significantly, such as moving from clinical audit to general compliance work with no degree requirement, the amended petition must re-establish specialty occupation status. Failing to amend can jeopardize your lawful status.
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