Senior Medical Coder

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:

• Verifying the coding of the diagnosis, evaluation and management, procedures, modifiers or other codes required for the completeness and accuracy of the record
• Review, examine and verify component parts of medical records:
  • Ensure completeness and accuracy of billed service
  • Consistency and completeness of coding using established CMS criteria and regulations
  • Authorized signatures and patient identification to ensure all documents contain sufficient documentation to support the diagnosis and treatment administered, and the results obtained are adequately described
• Review diagnosis, therapeutic and diagnostic procedures, supplies, materials, injections, and drugs with International Classification of Diseases (ICD10), Current Procedural Terminology (CPT), Heath Care Financing Administration Common Procedure Coding Systems (HCPCS - all levels, and any other coding classification systems that may be required)
• Coder Appeal Responsibilities:
  • Validate the claim denial reason and logic in our internal claim processing platforms and confirm that the logic is correctly applied according to CMS coding policies, including, but not limited to: NCCI Policy, NCD/LCD, Medicare Claim Processing Manuals
  • From a Part C perspective, we cannot use UHC payment policies unless there is a direct CMS source of truth to support
  • Search for information in cases where the coding is complex or unusual
  • Interpret appeal, validate claim processing, and tie that denial of service directly to a CMS policy that is both applicable to the date of service and provider specialty, to determine if the denial should be overturned or upheld
  • Ensure all the provider's arguments are reviewed and resolved with a concise timeline narrative/explanation including the direct sourcing to support the denial/uphold (if applicable)
• 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

Ability to navigate & understand functionality:

• COSMOS/Facets
• Claim forms
• ATS
• CMS.gov
• Outpatient Code Editor
• CES
• SAM edit

Required Qualifications:

• Bachelor's Degree or 5+ years of technical writing experience
• 5+ years' Coding and auditing experience E&M, CPT, HCPCS, Preferable Denial Coding
• Exposure in client interactions,
• Experience with spreadsheet and word processing management, such as Excel and Word
• Demonstrated ability to manage and prioritize deliverables
• Demonstrated excellent verbal and written communication skills
• Proven organizational skills with ability to be flexible and work with ambiguity
• Proven ability to work with minimal guidance; seek guidance on only the most complex tasks
• Proven attention to detail

Preferred Qualifications:

• Coding Certification (examples: CPC, CCS / CCS-P, RHIT, RHIA, etc.) or willing to obtain upon hire
• Experience with standard healthcare industry code sets such as E&M, CPT, HCPCS, ICD10, etc.
• Knowledge on Denials and Medicare & Medicaid policies and CMS Guidelines

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.