Coding Quality Analyst

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.   

The Clinical Professional Coding Analyst supports the Pre-Pay Claims Validation (PPCV) product within Commercial Fraud, Waste, Abuse, and Error for external commercial clients. 

In this role, you will perform complex clinical coding reviews to identify coding inaccuracies, documentation gaps, and opportunities to improve claim accuracy. Responsibilities include reviewing medical records and claims documentation, conducting coding analysis, supporting audit and validation activities, documenting findings and recommendations, and collaborating with internal and external partners to promote coding accuracy, quality, and compliance. The role also contributes to process improvement initiatives, coding education, and client-specific requirements.

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that is improving the lives of millions. Here, innovation is not about another gadget; it is about making health care data available wherever and whenever people need it, safely and reliably. There is no room for error. If you are looking for a better place to use your passion and your desire to drive change, this is the place to be. It's an opportunity to do your life's best work.

You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Perform clinical review of professional claims and supporting medical records to determine whether billed services are supported in accordance with applicable coding, reimbursement, and documentation requirements
• Maintain departmental productivity, quality, and accuracy standards as established by leadership
• Develop and communicate clear, concise, and defensible clinical rationales for review determinations
• Analyze claim, provider, and medical record data to identify discrepancies, billing concerns, and reimbursement opportunities
• Investigate, evaluate, and resolve claim review findings for commercial, government, and health plan customers
• Ensure compliance with applicable state and federal regulations, reimbursement policies, contractual requirements, and internal review guidelines
• Utilize critical thinking and clinical expertise to identify, research, and resolve issues within the scope of responsibility
• Accurately document review findings, determinations, and supporting rationale in applicable systems

Internal Collaboration and Customer Support:

• Attend team, department, and cross-functional meetings to provide feedback, share operational insights, and contribute to continuous improvement initiatives
• Partner with internal stakeholders across departments to identify opportunities, address challenges, and promote collaboration, accountability, and operational excellence
• Respond to internal and external inquiries and provide subject matter expertise to support business operations and organizational objectives
• Maintain effective working relationships with business partners to facilitate communication, issue resolution, and achieve shared goals

Continuing Education and Professional Development:

• Maintain required Coding Certification and/or Nursing Licensure in good standing, including completion of all continuing education, credentialing, and renewal requirements
• Stay current with coding guidelines, reimbursement methodologies, industry standards, regulatory changes, and departmental review processes
• Participate in ongoing training and educational opportunities to enhance clinical, coding, and payment integrity expertise

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:

• High School Diploma/GED
• Certified coder (CPC, COC, CPMA, CCS) OR Nursing Licensure
• 2+ years of experience in healthcare claims auditing, investigation and research
• 2+ years of experience multi-specialty coding experience including Evaluation and Management Services
• 2+ years of experience with Microsoft applications (OneNote, Teams, Excel, Outlook)

Preferred Qualifications:

• Intermediate knowledge of working on healthcare platforms (CAP, OPRS, FACETS, Encoder, EPIC, etc.)
• Intermediate knowledge of the healthcare insurance/managed care industry
• Intermediate knowledge of medical terminology and claim coding.
• Intermediate knowledge of Medicaid/Medicare Reimbursement methodologies
• An undergraduate degree or higher
• Strong analytical and problem-solving skills

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

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, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $24 - $43 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. 

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. 

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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