Note: The job is a remote job and is open to candidates in USA. Optum is hiring a Coding Quality Analyst to support its Pre-Pay Claims Validation product for commercial clients. The role reviews professional claims and medical records, identifies coding and documentation issues, documents defensible findings, and collaborates on audit, compliance, education, and process improvement activities.
Responsibilities
- Perform clinical review of professional claims and supporting medical records to determine whether billed services are supported in accordance with applicable coding, reimbursement, and documentation requirements
- Maintain departmental productivity, quality, and accuracy standards as 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
- Utilize critical thinking and clinical expertise to identify, research, and resolve issues within the scope of responsibility
- 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 across departments 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, issue resolution, and achieve shared goals
- Maintain required Coding Certification and/or Nursing Licensure in good standing, including completion of all 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
Skills
- High School Diploma/GED
- Certified coder (CPC, COC, CPMA, CCS) OR Nursing Licensure
- 2+ years of experience in healthcare claims auditing, investigation and research
- 2+ years of experience multi-specialty coding experience including Evaluation and Management Services
- 2+ years of experience with Microsoft applications (OneNote, Teams, Excel, Outlook)
- Intermediate knowledge of working on healthcare platforms (CAP, OPRS, FACETS, Encoder, EPIC, etc.)
- Intermediate knowledge of the healthcare insurance/managed care industry
- Intermediate knowledge of medical terminology and claim coding
- Intermediate knowledge of Medicaid/Medicare Reimbursement methodologies
- An undergraduate degree or higher
- Strong analytical and problem-solving skills
Benefits
- Telecommute from anywhere within the U.S.
- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
Company Overview
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