Role Description UPMC Health Plan has an exciting opportunity for a Special Investigations Unit Investigator position. This is a full time position working Monday through Friday daylight hours and is a remote position. The Special Investigations Unit (SIU) Investigator is responsible for investigating assigned fraud, waste and abuse (FWA) cases, as well as researching and analyzing claims data in order to identify potential FWA. The SIU Investigator is also responsible for maintaining the FWA case system with accurate and detailed investigative activities related to assigned cases. - Investigative actions include member/provider outreach, financial tracking, prepay claims review, adhering to compliance regulations, and making healthcare oversight referrals. - Plan, organize and execute investigations or audits utilizing document review, witness interviews, and data analysis to identify, evaluate and measure potential healthcare fraud and abuse to determine valid cases for appropriate action. - Risk Assessments on FWA trends using fraud detection software and/or as assigned by Manager. - Oversight or assistance with the Medicaid Recipient Restriction program. - Present FWA trainings to internal staff. - Assist with the FWA hotline and referral intake. - Perform chart reviews to assess compliance with coding and billing regulations. - Utilize standard coding guidelines, principles, and coding clinics to monitor the appropriate ICD and CPT codes for all record types to ensure accurate reimbursement. - Document and track activity in an internal database, provide case updates on the progress of the investigation and coordinate with management recommendations and further actions and/or resolutions. - Conduct detailed research to identify and apply appropriate regulatory, contractual, and industry requirements to the different benefits and products within investigations. - Maintain or exceed designated quality and production goals. - Understand and adhere to HIPAA privacy requirements. - Perform special projects as assigned by Management. Qualifications - Bachelor's Degree preferred or 2-4 years of related experience in investigations, claims, medical coding, auditing, compliance, risk management and/or data analysis required. - The ability to problem solve and communicate professionally. - Detail oriented individual with excellent organizational skills. - High degree of oral and written communication skills. - Proficiency in MS Office/PC skills including Microsoft Excel and Word. - Experience conducting investigations within a healthcare environment preferred. - Knowledge of CPT and ICD-10 coding of procedures and diagnosis is preferred. - Knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is preferred. Licensure, Certifications, and Clearances - CPT Preferred Company Description UPMC is an Equal Opportunity Employer/Disability/Veteran.

• Manage regulatory operations for complex oncology studies by preparing, submitting, and maintaining FDA, IRB, and institutional documentation in collaboration with Principal Investigators (PIs), ORAQ, sponsors, and internal stakeholders • Ensure compliance and audit readiness by maintaining complete regulatory binders, supporting monitoring and audit visits, responding to findings, and implementing corrective actions • Coordinate study and site management activities including site initiation, monitoring, close‑out, document storage, and sponsor/CRO communication using OnCore and eREG systems • Apply and interpret regulatory, institutional, and federal requirements to protocols, consent documents, SOPs, and operational plans, including support for international studies • Contribute to team leadership and training by mentoring peers, developing tools or resources, leading multidisciplinary meetings, and supporting process improvement initiatives

• On behalf of Rho’s clients, support and advise the CMC and related regulatory components of integrated development programs, including the review of technical documents, participation in technical discussions, and collaborations with CDMOs and other vendors. • Provide CMC regulatory-related leadership, guidance, and support to a team • Mentor and advise Rho staff in CMC regulatory strategy and product development by providing strategic and tactical guidance to team members, creating a strong sense of team unity and team identity, and providing regular and ongoing positive and corrective feedback to team members • Proactively identify risks and critically analyze problems affecting the programs and develop contingency plans as needed • Facilitate achievement of strategic goals for a program • Monitor ongoing progress of key CMC deliverables against Global Integrated Product Development Plan goals • Ensure effective, accurate and timely communication of key issues and progress to the team and senior management • Participate in the planning, preparation, and conduct of regulatory authority meetings; lead CMC discussions with regulatory authorities • Manage scope of work, budget, and timelines for external vendors, including consultants and external CMC writers • Participate in business development activities, including assisting in the identification and assessment of new opportunities, representing Rho at conferences and meetings, and conducting capture activities for anticipated proposals; provide guidance and input to the budgets and business submissions of proposals

• Conduct systematic reviews of procurement files to ensure compliance with CPSR standards, FAR/DFARS regulations, company policies, and contractual requirements. • Identify gaps, risks, and potential non-compliances; recommend and track corrective actions. • Assist in preparation, execution, and follow up activities for CPSR audits, including data calls, file population readiness, and auditor engagement. • Assist in the Development and maintenance of procurement policies, procedures, templates, checklists, and training materials. • Collaborate with procurement buyers, category managers, subcontract administrators, legal, and finance to strengthen compliant purchasing practices. • Provide one on one coaching and group training on CPSR critical elements such as price analysis, source justification, cost/price reasonableness, competition documentation, commercial item determinations, and subcontractor flow downs. • Monitor regulatory updates and interpret their implications for the procurement organization. • Support internal audit and continuous improvement initiatives to enhance the overall health of the purchasing system. • Assist with supplier evaluations, subcontract file closeout, and documentation control as required.