Coding Quality Auditor - E/M / ED

Requisition Number: 2356965
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:

• Perform comprehensive and specialty-specific audits of medical records to verify coding accuracy and documentation completeness, ensuring compliance with CPT, ICD 10, HCPCS, and organizational coding policies
• Execute focused reviews and ongoing monitoring projects based on risk indicators or identified trends
• Confirm that coding practices align with federal, state, and payer regulations including Medicare, Medicaid, HIPAA, and CMS guidelines
• Interpret and apply corporate and regulatory policies; assist in developing and updating audit-related procedures
• Track and document audit outcomes thoroughly, including methodology, results, corrective actions, and ongoing monitoring
• Investigate and identify trends, risk-prone areas, and coding issues like upcoding, under coding, unbundling, or modifier misuse
• Report audit outcomes, trends, and risks to senior compliance leadership (e.g., Chief Compliance Officer) and other stakeholders
• Prepare periodic reports (monthly, quarterly, annually), summarizing audit metrics, risk exposure, and remediation efforts
• Provide education and feedback to coders, billers, and clinical staff to reinforce correct coding practices and documentation standards
• Coordinate corrective action plans (CAPs), liaise with coding education teams, and verify their implementation
• Contribute to the creation and refinement of compliance audit frameworks, policies, workflows, and internal controls
• Stay abreast of evolving coding standards and regulatory updates, integrating them into auditing and policy practices
• Collaborate with compliance officers, internal audit teams, physician practices, management, and coding education departments
• Serve as a compliance expert in departmental or organizational meetings
• Identify and report potential fraud, waste, or abuse (FWA) related to billing irregularities
• Use data analysis to detect outliers, unusual patterns, and high-risk practices, enabling proactive mitigation
• Keep up to date with changes in coding guidelines (CMS, AMA, AHA coding clinics) and integrate them into team communication
• Responsible for tracking assessment scores, coding performance through audits, quality reviews, providing detailed feedback and guidance
• Support coders with complex case resolution, documentation improvement education, and coding clarification
• Collaborate with the compliance, QA and operations teams to identify coding gaps and ensure continuous improvement
• Support documentation improvement initiatives and coding clarification requests
• 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:

• Bachelor's degree in health information management, life science or a related field is preferred
• AAPC/AHIMA Certification is required: CPC/ CIC/ CCS/ COC/ CPMA
• 5+ years of hands-on E/M IP (Hospitalist) and E/M OP audit experience
• In-depth understanding of 2021 E&M or ED guideline changes and CMS documentation
• Solid understanding of medical terminology, anatomy, and physiology
• Solid Knowledge of US healthcare RCM system is required
• Familiarity with EMR/EHR, compliance standards, auditing platforms
• Proficiency in coding software and EHR systems (EPIC. eCAC, 3M, Cerner etc)
• Proficiency in using software and tools
• Proven solid organizational and time management skills
• Proven analytical thinking skills
• Proven excellent attention to detail and accuracy in coding and documentation
• Proven excellent communication and presentation skills

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.