Coding Quality Analyst
About The Position
The Clinical Professional Coding Analyst supports the Pre-Pay Claims Validation (PPCV) product within Commercial Fraud, Waste, Abuse, and Error for external commercial clients. The role performs complex clinical coding reviews to identify coding inaccuracies, documentation gaps, and opportunities to improve claim accuracy. It reviews medical records and claims documentation, conducts coding analysis, supports audit and validation activities, documents findings and recommendations, and collaborates 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. The position performs clinical review of professional claims and supporting medical records, evaluates claims against applicable coding, reimbursement, and documentation requirements, and communicates clear, defensible rationales for determinations. It supports commercial, government, and health plan customers while meeting departmental productivity, quality, and accuracy standards. The role is telecommutable from anywhere within the United States, subject to UnitedHealth Group’s Telecommuter Policy.
Requirements
- High school diploma or GED.
- Certified coder (CPC, COC, CPMA, or CCS) or nursing licensure.
- At least 2 years of experience in healthcare claims auditing, investigation, and research.
- At least 2 years of multispecialty coding experience, including Evaluation and Management Services.
- At least 2 years of experience with Microsoft applications, including OneNote, Teams, Excel, and Outlook.
- Maintain required coding certification and/or nursing licensure in good standing, including applicable continuing education, credentialing, and renewal requirements.
- Adhere to UnitedHealth Group’s Telecommuter Policy if telecommuting.
Nice To Haves
- Intermediate knowledge of healthcare platforms such as CAP, OPRS, FACETS, Encoder, or EPIC.
- Intermediate knowledge of the healthcare insurance or managed care industry.
- Intermediate knowledge of medical terminology and claim coding.
- Intermediate knowledge of Medicaid and Medicare reimbursement methodologies.
- An undergraduate degree or higher.
- Strong analytical and problem-solving skills.
Responsibilities
- Review professional claims and supporting medical records to determine whether billed services meet applicable coding, reimbursement, and documentation requirements.
- Maintain productivity, quality, and accuracy standards 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.
- Use critical thinking and clinical expertise to identify, research, and resolve issues within the role’s scope.
- Accurately document review findings, determinations, and supporting rationale in applicable systems.
- Attend team, department, and cross-functional meetings to provide feedback, share operational insights, and contribute to continuous improvement initiatives.
- Partner with internal stakeholders 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, resolve issues, and achieve shared goals.
- Maintain required coding certification and/or nursing licensure in good standing, including 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.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase program.
- 401(k) contribution.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
