Senior Coding Quality Analyst

About Optum

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.

Your Responsibilities

The Payment Integrity Coding Consultant position is responsible for determining medical appropriateness of inpatient and outpatient services following evaluation of medical documentation, and published CMS, Coding and other industry criteria. Conducts audits of medical coding to increase coding accuracy and identify potential FWAE. Completes comprehensive examinations of medical records and supporting documents. Provides support related to coding and billing issues to maintain compliance with policies, procedures, laws, and government regulations.

You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities

• Takes ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction
• FWAE detection and identification of aberrant behavior for providers and facilities
• Investigate, review and provide clinical and/or coding expertise in review of post-service, pre-payment or post-payment claims, which requires interpretation of state and federal mandates, billing practices/patterns, applicable benefit language, medical and reimbursement policies and coding requirements. Consideration of relevant clinical information on claims with overt billing patterns
• Make pay/deny recommendation decisions based on findings; this could include Medical Director/physician consultations and working independently while making decisions
• Identify updated clinical analytics opportunities and participate in projects as necessary
• Maintain and manage case review assignments
• Ensure issues are identified, tracked, reported and resolved
• Escalate issues as needed for support and/or guidance
• Keep abreast of current Medicare guidelines and regulations by reviewing updates, bulletins and changes to CMS manuals
• Performs all other related duties as assigned

Your Rewards

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

Required Qualifications

• Label: Associate’s Degree in Healthcare Administration, Business or a related field OR High School Diploma/GED with 2+ years of relevant experience above required years of experience may be considered in lieu of Associate’s Degree
• Label: Coding certification through AAPC or AHIMA
• Label: 3+ years of experience in medical claims professional procedure coding and processing
• Label: 3+ years of experience reading, interpreting and applying Medicare and CMS Claims and Policies (NCD/LCD/NCCI)

Preferred Qualifications

• 3+ years in a Medical Insurance environment
• Experience working in Payment Integrity, Fraud Waste and Abuse or Special Investigations
• Experience in communicating complicated concepts and information to a wide range of audiences
• Experience working with process improvement teams and streamlining processes as required and improving departmental efficiencies
• Experience with Encoder Pro
• Experience with IKA platform
• Live in a location where there is a United Health Group approved high-speed internet connection or leverage an existing high-speed internet service
• Proven solid analytical and research skills
• Proven excellent written and verbal communication skills

Physical & Mental Requirements

• Ability to sit for extended periods of time
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving
• All Telecommuters will be required to adhere to United Health Group’s Telecommuter policies and guidelines.