Clinical Auditor Jobs in USA with Visa Sponsorship
Clinical Auditor roles qualify for H-1B visa and TN visa sponsorship when tied to a healthcare or quality assurance degree. Employers in hospital systems, insurance networks, and CMS-regulated facilities regularly sponsor, though roles vary significantly in how they structure LCA filings and prevailing wage tiers. For detailed occupation requirements, see the O*NET profile.
See All Clinical Auditor JobsOverview
Showing 5 of 28+ Clinical Auditor jobs
Have you applied for this role?
Have you applied for this role?
Have you applied for this role?
Have you applied for this role?
Have you applied for this role?
See all 28+ 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 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 28+ 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 Visa Sponsorship as a Clinical Auditor
Confirm your degree aligns with the role
Clinical Auditor positions typically require a degree in nursing, health information management, healthcare administration, or a related clinical field. A general business or unrelated degree may not satisfy the specialty occupation requirement for H-1B sponsorship.
Target employers with CMS compliance obligations
Hospital systems, Medicare Advantage plans, and accredited health networks face federal audit requirements, making them more likely to sponsor clinical auditors long-term. These organizations have established HR and legal infrastructure to support the visa process efficiently.
Understand how the LCA wage tier affects your offer
Your employer must file a Labor Condition Application certifying your wage meets the prevailing level for Clinical Auditor in your metro area. Roles coded under healthcare quality occupations may fall into different SOC categories, directly affecting the required wage tier.
Ask whether the employer has sponsored this role before
Some healthcare employers sponsor frequently for clinical or IT roles but have never processed an H-1B for a Clinical Auditor specifically. Prior experience with your exact role type reduces processing delays and signals the employer understands the specialty occupation requirements involved.
Consider TN status if you hold Canadian or Mexican citizenship
Canadian and Mexican nationals may qualify for TN visa status under the medical or health management professional categories, depending on the role's specific duties. TN processing is faster than H-1B and bypasses the annual lottery entirely, making it worth evaluating early.
Document your clinical credentials alongside your degree
Certifications such as RHIA, CPC, CPHQ, or CCS strengthen a specialty occupation argument for Clinical Auditor roles. Employers and immigration attorneys use these to demonstrate that the position requires specialized knowledge beyond a generalist background.
Clinical Auditor jobs are hiring across the US. Find yours.
Find Clinical Auditor JobsFrequently Asked Questions
Does a Clinical Auditor role qualify as a specialty occupation for H-1B purposes?
Yes, in most cases, provided the employer can demonstrate the position normally requires at least a bachelor's degree in a specific field like health information management, nursing, or healthcare administration. Roles where any degree suffices risk an RFE. The strongest petitions tie the auditing duties directly to clinical knowledge that a degree in a specific discipline provides.
Which visa types are most commonly used to sponsor Clinical Auditors?
H-1B is the most common pathway, with TN status available for Canadian and Mexican nationals whose duties align with eligible health professional categories. Some employers use O-1A for candidates with recognized credentials or publications in clinical quality. E-3 applies to Australian citizens. The right visa depends on your nationality, degree, and the role's specific responsibilities.
How can I find Clinical Auditor jobs that offer visa sponsorship?
Migrate Mate filters job listings specifically for visa sponsorship willingness, which makes it far more efficient than searching general job boards and guessing at employer policies. Clinical Auditor roles with active LCA filings or verified sponsorship history appear on the platform, so you can focus applications on employers already set up to support the process.
Will a nursing or clinical background help or hurt my sponsorship case?
It helps significantly. Clinical Auditor roles at hospitals and payers are strongest as specialty occupations when the candidate holds a clinical degree, because auditing medical records, DRG coding accuracy, or care quality requires domain-specific knowledge. A nursing or health informatics background directly supports the argument that a specialized degree is a genuine requirement of the position.
Can a Clinical Auditor role be sponsored at a remote or contract position?
Remote sponsorship is possible but adds complexity. H-1B requires an LCA tied to a worksite location, and fully remote roles must list all locations where work is regularly performed, which can trigger additional prevailing wage requirements. Contract-to-hire arrangements through staffing agencies are possible but split H-1B responsibility between the agency and the end client, requiring careful structuring with immigration counsel.
What is the prevailing wage requirement for sponsored Clinical Auditor jobs?
U.S. employers sponsoring a visa must pay at least the prevailing wage, which is what workers in the same role, area, and experience level typically earn. The Department of Labor sets this rate to make sure companies aren't hiring foreign workers simply because they'd accept lower pay than a U.S. worker. It varies by job title, location, and experience. You can look up current prevailing wage rates for any occupation and location using the OFLC Wage Search page.
See which Clinical Auditor employers are hiring and sponsoring visas right now.
Search Clinical Auditor Jobs