Optum is a global organization focused on improving health outcomes through technology, care, pharmacy benefits, data, and resources. This role supports a telecommuting environment and involves reviewing medical claims for coding accuracy, compliance, and payment integrity.
The Medical Coding Auditor reviews claims against submitted medical records to identify waste, error, fraud, and abuse indicators. The role requires sound judgment on complex payment decisions, strong analytical skills, and the ability to communicate findings clearly in writing.
Primary responsibilities
- Perform clinical review of CPT, HCPCS, and modifier codes assigned to claims in a telecommuting work environment
- Determine accuracy of medical coding, billing, and payment recommendations
- Interpret state and federal mandates, benefit language, medical policies, and reimbursement policies
- Determine appropriate level of service using Evaluation and Management coding principles
- Provide detailed clinical narratives on case outcomes
- Ensure adherence to compliance, reimbursement, and contract policies
- Identify aberrant billing patterns and trends and recommend cases for further review
- Manage daily case review assignments while meeting quality, utilization, and productivity standards
- Provide clinical support and expertise to investigative and analytical teams
- Participate in team and department meetings
- Work independently and collaboratively as needed
- Serve as a clinical resource within the clinical investigative team
- Work with business partners to obtain additional information relevant to clinical review
Required qualifications
- Certified coder through AHIMA or AAPC: CCA, CCS, CCS-P, CPC, or CPC-I
- 2+ years of experience as an AHIMA or AAPC certified coder
- 2+ years of CPT, HCPCS, and modifier coding experience
- 2+ years of strong medical record review experience
- 1+ year of experience in a metric-driven team environment with daily production and quality standards
- 1+ year of experience in the health insurance industry using industry terminology and regulatory guidelines
- 1+ year of experience with waste and error principles
Preferred qualifications
- Healthcare claims processing experience
- Experience with fraud, waste, and abuse or payment integrity
- Experience with UHC platforms such as COSMOS, Facets, CPW, NICE, ISET, or UNET
- Ability to navigate multiple systems at once with varying complexity
- Strong computer troubleshooting skills
- Intermediate experience with Microsoft and Adobe applications including Outlook, PowerPoint, Word, Excel, OneNote, Teams, and PDF tools
Soft skills
- Highly organized with effective communication skills
- Strong written communication skills
- Ability to adapt to change and integrate best practices
- Strong analytical skills with medical terminology and coding
- Ability to work independently in a remote environment
Comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution, subject to eligibility requirements.
Location
Minnesota, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
1 month ago