UPMC Health Plan has an exciting opportunity for a Business Analyst position in the Fraud, Waste & Abuse department. This is a full time position working Monday through Friday daylight hours. This is a remote position.
The Business Analyst supports the UPMC Health Plan Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) activities through advanced data analysis, risk‑based monitoring, and regulatory reporting. This role partners with Claims, Legal, Compliance, and IT to identify program integrity risks and support healthcare investigations and audits.
Responsibilities:
- Analyze large, complex healthcare datasets to identify patterns, trends, and potential fraud, waste, and abuse
- Develop and maintain risk‑based monitoring and executive‑level dashboards
- Create metrics, trend analyses, and regulatory reports (Medicaid, Medicare, FEHB, CHIP)
- Pull and analyze claims and operational data to support audits and investigations
- Develop RAT‑STATS samples and perform extrapolation analyses
- Translate business needs into data‑driven insights and reporting solutions
- Maintain documentation, workflows, and project materials
- Ensure data accuracy, confidentiality, and compliance with regulatory requirements
Preferred Qualifications:
- Experience in Health Insurance, Claims Operations, FWA/SIU preferred.
- Highly organized with strong attention to detail
- Knowledge of CPT, HCPCS, and ICD‑10 coding and common FWA schemes preferred.
- Strong analytical skills with the ability to communicate findings to executive audiences preferred.
- Experience creating dashboards, reports, and compliance documentation preferred.
Licensure, Certifications, and Clearances:
- Act 34
UPMC is an Equal Opportunity Employer/Disability/Veteran