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.
Primary Responsibilities
- Lead clinical evaluation of fraud, waste, and abuse (FWA) scenarios across US healthcare claims with deep coding and policy expertise
- Drive interpretation of complex reimbursement policies (CMS, NCCI, LCD/NCD) and translate into actionable payment integrity insights
- Act as a clinical subject matter expert (SME) for high-risk coding patterns including DRG shifts, E/M upcoding, and modifier misuse
- Evaluate advanced clinical scenarios including multi-specialty billing, inpatient vs outpatient coding differences, and bundled services
- Provide clinical thought leadership in identifying emerging payment integrity risks across provider types and specialties
- Collaborate closely with onshore clinical teams to align on policy interpretation and review standards
- Own clinical validation strategy ensuring high true positive rates and minimal provider abrasion
- Support strategic initiatives to enhance clinical rigor in analytics-driven PI programs
- Perform deep clinical review of professional and institutional claims to detect FWA and coding inaccuracies
- Interpret CPT, HCPCS, ICD-10-CM, DRG, modifiers, and revenue codes in highly complex billing scenarios
- Apply advanced CMS policies, NCCI edits, MUEs, and medical necessity rules for claim validation
- Lead development of clinically robust rules covering unbundling, upcoding, duplicate billing, and non-covered services
- Validate rule outputs through detailed chart/claim review and clinical reasoning
- Define inclusion/exclusion logic with strong clinical justification and payer alignment
- Mentor junior analysts on coding accuracy, policy interpretation, and clinical review techniques
- Partner with analytics teams to ensure accurate clinical translation into data models and outputs
- Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so
Required Qualifications
- Undergraduate degree or equivalent experience
- 8+ years of experience in US healthcare payment integrity, coding, or clinical claims review
- Solid experience interpreting CMS manuals, NCCI policies, LCD/NCD, and payer guidelines
- Experience reviewing complex specialties (surgery, inpatient DRG, E/M, radiology, etc)
- Expert-level knowledge of CPT, HCPCS, ICD-10-CM, DRG, modifiers, and billing practices
- Deep understanding of medical necessity, diagnosis-procedure relationships, and documentation requirements
- Proven solid ability to translate clinical findings into business and payment integrity actions
- Proven excellent communication skills for leadership and stakeholder discussions
Preferred Qualifications
- Experience in leading PI initiatives or large-scale FWA programs
- Experience working with clinical SMEs, auditors, and policy teams
- Experience creating audit-ready documentation and provider rationale
- Leadership or mentoring experience within analytics or PI teams
- Exposure to claim audits, DRG validation, and clinical documentation review
- Solid knowledge of Medicare Advantage and commercial payer nuances
- Familiarity with analytics tools (SQL/Tableau) to validate outputs (not mandatory)
- Demonstrated ability to drive concept ideation and clinical strategy for PI programs
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.