Professional Pre-Pay Medical Coding Auditor

UnitedHealth Group•Plymouth, MN

1d•$24 - $43•Remote

About The Position

The Medical Coding Auditor is required to determine the accuracy of claims submitted by a provider to UnitedHealth Group by comparing it to the medical record(s) submitted for the date(s) of service being reviewed. This position supports the identification of suspected Waste & Error of health insurance claims and ensures claims are accurately documented. Candidates must be able to exercise judgement/decision making on complex payment decisions that directly impacts the provider and client by following state and government compliance guidelines, coding requirements and policies. They must confidently analyze and interpret data and medical records/documentation daily to understand historical claims activity, determine validity and demonstrate their ability to provide written communication to the provider. They are responsible to investigate, review and provide clinical and/or coding expertise in a review of claims. They need to effectively manage their caseload and monthly metrics in a production driven environment and ensure they are meeting all compliance turnaround times mandated by the client. The Coding Quality Analyst must be proficient in computer skills and able to navigate multiple systems at one time with varying levels of complexity. They must have the ability to research and work independently on making decisions on complex cases.

Requirements

Certified Coder AHIMA (CCA, CCS, CCS-P) or AAPC Certified coder (CPC, CPC-I)
2+ years of experience as an AHIMA or AAPC Certified coder
2+ years of CPT/HCPCS/Modifiers coding experience
2+ years strong medical record review experience
1+ year of working in a team atmosphere in a metric driven environment including daily production standards and quality standards
1+ years of experience in the health insurance business, using industry terminology and regulatory guidelines
1+ years of experience in Waste & Error principles
Proficient and able to navigate and maneuver multiple systems at one time with varying levels of complexity
Strong computer skills with the ability to troubleshoot problems
Intermediate experience with Microsoft & Adobe applications (Outlook, Power Point, Word, Excel, OneNote, Teams, PDF)
Highly organized with effective and persuasive communication skills
Strong written communication skills
Open to change and new information; ability to adapt in changing environments and integrate best practices
Strong communication skills with the ability to interpret data
Strong analytical mindset working with medical terminology and/or coding
All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Nice To Haves

Healthcare claims experience/processing experience
Experience with Fraud Waste & Abuse or Payment Integrity
[Internal Posting Only] 1+ year experience of UHC platforms - COSMOS, Facets, CPW, NICE, ISET, UNET

Responsibilities

Performs clinical review of CPT, HCPCS, and modifiers assigned to codes on claims in a telecommuting work environment
Determines accuracy of medical coding/billing and payment recommendation for claims
This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies, and consideration of relevant clinical information
Determines appropriate level of service utilizing Evaluation and Management coding principles
Provides detailed clinical narratives on case outcomes
Ensures adherence to state and federal compliance policies, reimbursement policies and contract compliance
Identifies aberrant billing patterns and trends, evidence of fraud, waste, or abuse, and recommends providers to be flagged for review
Maintains and manages daily case review assignments, with accountability to quality, utilization, and productivity standards
Provides clinical support and expertise to the other investigative and analytical areas
Participates in team and department meetings
Engages in a collaborative work environment when applicable but is also able to work independently
Serves as a clinical resource to other areas within the clinical investigative team
Work with applicable business partners to obtain additional information relevant to the clinical review