Professional Pre-Pay Medical Coding Auditor

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best.

Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale.

Join us to start Caring. Connecting. Growing together.

You’ll enjoy the flexibility to telecommute
* as you take on some tough challenges.

The Medical Coding Auditor is required to determine the accuracy of claims submitted by a provider to United Health Group by comparing it to the medical record(s) submitted for the date(s) of service being reviewed. This position supports the identification of suspected Waste & Error of health insurance claims and ensures claims are accurately documented. Candidates must be able to exercise judgement/decision making on complex payment decisions that directly impacts the provider and client by following state and government compliance guidelines, coding requirements and policies.

They must confidently analyze and interpret data and medical records/documentation daily to understand historical claims activity, determine validity and demonstrate their ability to provide written communication to the provider. They are responsible to investigate, review and provide clinical and/or coding expertise in a review of claims. They need to effectively manage their caseload and monthly metrics in a production driven environment and ensure they are meeting all compliance turnaround times mandated by the client.

The Coding Quality Analyst must be proficient in computer skills and able to navigate multiple systems at one time with varying levels of complexity. They must have the ability to research and work independently on making decisions on complex cases.

• Performs clinical review of CPT, HCPCS, and modifiers assigned to codes on claims in a telecommuting work environment
• Determines accuracy of medical coding/billing and payment recommendation for claims
• This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies, and consideration of relevant clinical information
• Determines appropriate level of service utilizing Evaluation and Management coding principles
• Provides detailed clinical narratives on case outcomes
• Ensures adherence to state and federal compliance policies, reimbursement policies and contract compliance
• Identifies aberrant billing patterns and trends, evidence of fraud, waste, or abuse, and recommends providers to be flagged for review
• Maintains and manages daily case review assignments, with accountability to quality, utilization, and productivity standards
• Provides clinical support and expertise to the other investigative and analytical areas
• Participates in team and department meetings
• Engages in a collaborative work environment when applicable but is also able to work independently
• Serves as a clinical resource to other areas within the clinical investigative team
• Work with applicable business partners to obtain additional information relevant to the clinical review

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

• Certified Coder AHIMA (CCA, CCS, CCS-P) or AAPC Certified coder (CPC, CPC-I)
• 2+ years of experience as an AHIMA or AAPC Certified coder
• 2+ years of CPT/HCPCS/Modifiers coding experience
• 2+ years strong medical record review experience
• 1+ year of working in a team atmosphere in a metric driven environment including daily production standards and quality standards
• 1+ years of experience in the health insurance business, using industry terminology and regulatory guidelines
• 1+ years of experience in Waste &…