Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
The Outpatient Coding Compliance Auditor performs audits of outpatient facility (OPPS) coding to ensure accurate assignment of ICD-10-CM diagnoses, CPT/HCPCS codes, modifiers, and facility E/M levels (ACEP or client-specific). This role reviews coding for alignment with medical record documentation and established guidelines, ensuring compliance with applicable laws, regulations, and billing standards while effectively communicating findings to stakeholders. The Auditor also analyzes audit outcomes to identify trends, determine root causes, and pinpoint opportunities for improvement, as well as assess the effectiveness of corrective actions. Additionally, as part of the Compliance Workplan the Auditor participates in quality assurance (QA) coding oversight, conducts independent reviews, and supports organizational compliance initiatives.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Perform coding compliance and quality audits in support of Optum Insight Provider's Compliance Program and client expectations
- Independently analyze and interpret clinical documentation from medical records
- Validate coding accuracy for outpatient facility, including E/M services, procedures, and modifiers
- Identify audit findings, calculate billing error rates, and perform root cause analysis to determine drivers of non-compliance
- Assess and evaluate the adequacy and effectiveness of corrective action plans, providing follow-up validation as appropriate
- Clearly document audit findings and articulate results tailored to the appropriate audience
- Prepare written audit analysis and summary reports, including compliance risk, trends, and recommended corrective actions
- Conduct ad hoc coding and billing audits as requested
- Provide compliance oversight of QA audit activities, ensuring consistency and adherence to established standards
- Audit vendor coders and auditors, including offshore staff
- Monitor and track evolving industry trends, regulatory updates, and government audit activities to identify potential coding and billing risk areas
- Stay current with applicable coding, billing, and regulatory guidelines
- Research, develop, and present targeted education based on individual, team, and systemic audit findings
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or Certified Outpatient Coder (COC)
- 5+ years of Outpatient Facility coding experience including:
- NCCI/OCE billing edits related to outpatient services coding and billing
- ICD-10-CM and CPT (including CPT-4)
- ACEP Facility or similar Facility E/M matrix guidelines for outpatient facility code assignment
- 5+ years of Outpatient Facility audit experience, including surgery, observation, and emergency department, including: (Strong industry knowledge of Medicare regulations and payment policies, including OPPS)
Preferred Qualifications:
- Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Professional Medical Auditor (CPMA) a plus
- Demonstrated ability to perform independent, autonomous audit and coding review functions
- Strong professional communication skills, both oral and written
- Ability to prioritize and manage multiple assignments, spreadsheets, documents, and reports
- Proven time management skills with consistent follow-through to completion
- Proficiency with Microsoft Excel, Teams, PowerPoint, Word, and Outlook
*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
***Application Deadline:***This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
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