What are the responsibilities and job description for the Clinical Auditor position at Upper Peninsula Health Plan?
POSTED: March 4, 2025
POSITION: Clinical Auditor
DEPARTMENT: Special Investigations Unit (SIU)
BASE RATE: $28.26 per hour, with potential for additional compensation based on qualifications.
POSITION SUMMARY:
Under the supervision of the Compliance Officer, the Clinical Auditor is responsible for planning and conducting operational, compliance, and regulatory audits to ensure objective evaluation of the organization’s activities with a clinical focus. The Clinical Auditor will collect, analyze, and interpret data and results to validate compliance or identify opportunity for internal controls and/or operating procedures.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.
2. Participates in the creation and support of the compliance program.
3. Primary lead for clinically focused audits and assists other auditors if clinical review is needed.
4. Plans and conducts audits of internal controls, routine operations, and ad-hoc audits, as necessary.
5. Collects, analyzes, and interprets data and information to prepare audit and control reports; communicates and discusses audit findings with appropriate parties and/or as requested; develops and maintains audit reports.
6. Ensures that medical record documentation supports billed procedure codes.
7. Updates and develops new audit reports by identifying and defining issues, developing criteria, and reviewing and analyzing contracts and regulations.
8. Collaborates with Compliance Officer, colleagues, and internal/external agents as required; develops and maintains constructive and cooperative working relationships.
9. Assists Compliance Officer with subcontractor oversight.
10. Maintains professional and technical knowledge by attending educational workshops and conferences, reviewing professional publications, and continuing education as requested.
11. Maintains confidentiality of client data.
12. Performs other related duties as assigned or requested.
POSITION QUALIFICATIONS:
Education:
Minimum:
Associate degree in nursing
Preferred:
Bachelor’s degree in nursing
Requirement:
Licensed in the state of Michigan
Experience:
Minimum:
Three (3) years of clinical or health related experience
Preferred:
Prior auditing or consulting experience in a payer environment; experience with a variety of systems and technologies; auditing or coding certification a plus.
Required Skills:
Working knowledge of Microsoft Office (Word, Excel, and Outlook) Keyboarding proficiency
Excellent human relation and oral/written communication
Excellent organizational and prioritization abilities
Ability to successfully plan, organize, and manage audit projects
Critical thinking and analytic skills
Desired Skills:
Detail oriented
Ability to work both independently and collaboratively within a team
Knowledge of InterQual guidelines
Knowledge of UPHP policies and procedures
Knowledge of federal, state, and contractual regulations and requirements
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria.
Physical Requirements:
[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:
Ability to enter and access information from a computer
Ability to access all areas of the UPHP offices
Occasionally lifts supplies/equipment
Prolonged periods of sitting
Manual dexterity
Working Conditions:
Works in office conditions, but occasional travel may be required
Exposure to situations requiring exceptional interpersonal skills or periods of intense concentration
Subject to many interruptions
Occasionally subjected to irregular hours
Salary : $28
