Medical Coding Auditor

UnitedHealth GroupMinneapolis, MN, US

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Caring. Connecting. Growing Together.

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.

Medical Coding Auditor

The Medical Coding Auditor is required to determine the accuracy of claims submitted by a provider to UnitedHealth 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 impact 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 for investigating, reviewing 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.

You will enjoy the flexibility to telecommute

from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities :

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

Participate 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

Required Qualifications :

High School Diploma / GED (or higher)

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 of strong medical record review experience

1+ years of experience 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 & Error principles

Preferred Qualifications :

Healthcare claims experience / processing experience

Experience with Fraud Waste & Abuse or Payment Integrity

Internal Posting Only) 1+ years of experience with UHC platforms - COSMOS, Facets, CPW, NICE, ISET, UNET

Proficient and able to navigate and maneuver multiple systems at one time with varying levels of complexity

Strong computer skills with the ability to troubleshoot problems

Intermediate level of proficiency with Microsoft & Adobe applications (Outlook, Power Point, Word, Excel, OneNote, Teams, PDF)

Soft Skills :

Highly organized with effective and persuasive communication skills

Strong written communication skills

Open to change and new information; ability to adapt in changing environments and integrate best practices

Strong communication skills with the ability to interpret data

Strong analytical mindset working with medical terminology and / or coding

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, youll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $23.41 to $41.83 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

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Medical Coding Auditor • Minneapolis, MN, US