Requisition Number: 2189610
Job Category: Medical & Clinical Operations
Primary Location: Dallas, TX
You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
The Coding Quality Analyst 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 identification of suspected Waste & Error of health insurance claims and ensures claims are accurately documented. Candidate 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.
This position is full-time, Monday – Friday. Employees are required to work our normal business hours of 8:30am – 4:30pm. It may be necessary, given the business need, to work occasional overtime or weekends.
We offer 6-7 weeks of paid training. The hours during training will be 8:30am to 4:30pm, Monday – Friday. Training will be conducted virtually from your home.
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
- 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.
- Perform claim recoding (Post Pay only)
- 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.
- Associate’s Degree (or higher)
- Certified Coder AHIMA (CCA, CCS, CCS-P) or AAPC Certified coder (CPC, CPC-I) with unrestricted license, or currently in coding academy
- 2+ years of experience as an AHIMA or AAPC Certified coder with 2+ years of CPT/HCPCS/ICD – 10/CM/PCS coding experience or Licensed nurse with medical record auditing and coding/billing experience
- 1+ years of working in a team atmosphere in a metric driven environment including daily production standards and quality standards
- Medical record review experience
- Understanding of Waste & Error principles
- Knowledge of health insurance business, industry terminology, and regulatory guidelines
- Intermediate experience with Microsoft & Adobe applications (Outlook, Power Point, Word, Excel, OneNote, Teams, PDF)
- Experience must include CPT/HCPCS/Modifiers (Medical necessity and DRG review experience is not applicable to this position)
- Ability to work our normal business hours of 8:30am – 4:30pm. It may be necessary, given the business need, to work occasional overtime or weekends
- Bachelor’s Degree (or higher)
- Nurse (RN, LPN)
- Healthcare claims experience/processing experience
- Experience with Fraud Waste & Abuse or Payment Integrity
- Analytical mindset working with medical terminology or coding
- Ability to keep all company sensitive documents secure (if applicable)
- Required to have a dedicated work area established that is separated from other living areas and provides information privacy.
- Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.
- Strong computer skills with the ability to troubleshoot problems
- 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
- Must be proficient and able to navigate and maneuver multiple systems at one time with varying levels of complexity.
- Strong communication skills with the ability to interpret data.
California, Colorado, Connecticut, Nevada, New Jersey, New York, Washington or Rhode Island Residents Only: The salary range for California / Colorado / Connecticut / Nevada / New Jersey / New York / Washington / Rhode Island residents is $22.45 – $43.89.Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives
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