[Hiring] Outpatient Facility Coding Compliance Auditor @UnitedHealth Group

Role Description

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

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

Requirements

• 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

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)