C&S Clinical Coding Analyst
About The Position
The C&S Clinical Coding Analyst reviews pre-payment claims by comparing provider-submitted claims with medical records for the dates of service under review. The role requires exercising judgment on complex payment decisions that affect providers and UnitedHealth Group or its clients while following applicable state and federal compliance guidelines, coding requirements, and policies. The analyst investigates claims, applies clinical and coding expertise, analyzes historical claims activity and documentation, determines claim validity, and communicates findings in writing to providers. The analyst reviews CPT, HCPCS, and modifier coding, assesses medical coding, billing, and payment recommendations, and determines appropriate service levels using Evaluation and Management coding principles. The role also involves identifying unusual billing patterns and potential fraud, waste, or abuse; managing daily case assignments and performance metrics; meeting compliance turnaround times; and providing clinical support to investigative and analytical teams. The position is remote within the United States and requires navigating multiple computer systems, working independently on complex cases, and collaborating with relevant business partners and team members.
Requirements
- High school diploma or GED.
- AHIMA- or AAPC-certified coder credential, such as CPC, CCS, or CCS-P.
- At least 2 years of experience as an AHIMA- or AAPC-certified coder, including at least 2 years of CPT, HCPCS, ICD-10-CM/PCS, and modifier coding experience.
- At least 2 years of experience with the health insurance business, industry terminology, and regulatory guidelines.
- At least 1 year of experience working in a team environment with metrics, including daily production and quality standards.
- Intermediate experience reviewing medical records.
- Intermediate computer skills, including the ability to troubleshoot problems.
- Intermediate experience with Microsoft and Adobe applications, including Outlook, PowerPoint, Word, Excel, and PDF.
- Ability to manage and navigate multiple computer systems of varying complexity.
- Must adhere to UnitedHealth Group’s Telecommuter Policy if telecommuting.
- Must pass a drug test before beginning employment.
Nice To Haves
- Bachelor’s degree.
- Healthcare claims or claims processing experience.
- Strong communication skills and ability to interpret data.
- Experience with Fraud, Waste & Abuse or Payment Integrity.
- Experience with subsequent or reconsideration reviews for FWAE.
- Strong analytical mindset and experience with medical terminology or coding.
Responsibilities
- Perform quality audits of clinical review cases involving CPT, HCPCS, and modifiers assigned to claim codes in a telecommuting work environment.
- Determine the accuracy of medical coding and billing and recommend payment outcomes for pre-payment claims.
- Consult with medical directors or physicians as needed and interpret state and federal mandates, benefit language, medical and reimbursement policies, and relevant clinical information.
- Determine appropriate levels of service using Evaluation and Management coding principles.
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract requirements.
- Identify aberrant billing patterns and trends and potential fraud, waste, or abuse, and recommend providers for review.
- Manage daily case review assignments and meet quality, utilization, productivity, and compliance turnaround standards.
- Provide clinical support and expertise to investigative and analytical areas and serve as a clinical resource within the clinical investigative team.
- Participate in team and department meetings and collaborate when appropriate while also working independently.
- Work with business partners to obtain information relevant to clinical reviews.
- Analyze medical records and historical claims activity and provide written communication to providers.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs, subject to eligibility requirements.
- Equity stock purchase, subject to eligibility requirements.
- 401(k) contribution, subject to eligibility requirements.
- Career development opportunities.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
