Medical Coding Auditor
About The Position
The Medical Coding Auditor reviews claims submitted by providers to UnitedHealth Group and compares them with medical records for the dates of service under review. The role identifies suspected waste and errors, verifies documentation accuracy, and makes complex payment decisions in accordance with state and government compliance guidelines, coding requirements, and policies. The auditor analyzes claims history and medical documentation, investigates cases, provides clinical and coding expertise, and communicates findings to providers in writing. The position requires independent judgment, effective caseload management, and meeting production, quality, and client-mandated turnaround standards in a telecommuting environment. The role may be performed remotely from anywhere within the United States, subject to UnitedHealth Group’s Telecommuter Policy.
Requirements
- Current AHIMA coder certification (CCA, CCS, or CCS-P) or AAPC coder certification (CPC or CPC-I).
- At least 2 years of experience as an AHIMA- or AAPC-certified coder.
- At least 2 years of CPT, HCPCS, and modifier coding experience.
- At least 2 years of medical record review experience.
- At least 1 year working in a team environment with metrics, daily production standards, and quality standards.
- Strong organizational, persuasive communication, written communication, analytical, and data interpretation skills.
- Ability to adapt to change and new information and integrate best practices.
- Ability to work independently on complex cases and navigate multiple systems of varying complexity.
- Proficient computer skills and ability to troubleshoot problems.
- Adherence to UnitedHealth Group’s Telecommuter Policy for telecommuters.
- Must pass a drug test before beginning employment.
Nice To Haves
- Experience in the health insurance business, including industry terminology and regulatory guidelines.
- Experience with Waste & Error principles.
- Healthcare claims or claims processing experience.
- Experience with Fraud, Waste & Abuse or Payment Integrity.
- For internal applicants only: at least 1 year of experience with UHC platforms, including COSMOS, Facets, CPW, NICE, ISET, or UNET.
- Intermediate experience with Microsoft and Adobe applications, including Outlook, PowerPoint, Word, Excel, OneNote, Teams, and PDF.
Responsibilities
- Perform clinical review of CPT, HCPCS, and modifiers assigned to claims in a telecommuting work environment.
- Determine the accuracy of medical coding and billing and recommend claim payment outcomes.
- Consult Medical Directors or physicians when appropriate and interpret state and federal mandates, benefit language, medical and reimbursement policies, and relevant clinical information.
- Determine the appropriate level of service using Evaluation and Management coding principles.
- Provide detailed clinical narratives documenting case outcomes.
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract requirements.
- Identify aberrant billing patterns and trends and evidence of fraud, waste, or abuse; 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 teams and serve as a clinical resource within the clinical investigative team.
- Work with business partners to obtain additional information relevant to clinical reviews.
- Participate in team and department meetings and collaborate while also working independently.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase.
- 401(k) contribution.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
