Optum ยท 3 weeks ago
Senior Coding Quality Analyst
San Antonio, TX
Full-time
Hybrid
Mid, Senior Level
$28.27/hr - $50.48/hr
3+ years expOptum is a global organization dedicated to delivering care through technology to improve health outcomes. The Senior Coding Quality Analyst role involves determining the medical appropriateness of services, conducting audits, and providing support for coding and billing issues to ensure compliance with regulations.
EducationHealth CareMedicalPharmaceutical
Responsibilities
Takes ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction
FWAE detection and identification of aberrant behavior for providers and facilities
Investigate, review and provide clinical and/or coding expertise in review of post-service, pre-payment or post-payment claims, which requires interpretation of state and federal mandates, billing practices/patterns, applicable benefit language, medical and reimbursement policies and coding requirements. Consideration of relevant clinical information on claims with overt billing patterns
Make pay/deny recommendation decisions based on findings; this could include Medical Director/physician consultations and working independently while making decisions
Identify updated clinical analytics opportunities and participate in projects as necessary
Maintain and manage case review assignments
Ensure issues are identified, tracked, reported and resolved
Escalate issues as needed for support and/or guidance
Keep abreast of current Medicare guidelines and regulations by reviewing updates, bulletins and changes to CMS manuals
Performs all other related duties as assigned
Qualification
Required
Associate's Degree in Healthcare Administration, Business or a related field OR High School Diploma/GED with 2+ years of relevant experience above required years of experience may be considered in lieu of Associate's Degree
Coding certification through AAPC or AHIMA
3+ years of experience in medical claims professional procedure coding and processing
3+ years of experience reading, interpreting and applying Medicare and CMS Claims and Policies (NCD/LCD/NCCI)
Preferred
3+ years in a Medical Insurance environment
Experience working in Payment Integrity, Fraud Waste and Abuse or Special Investigations
Experience in communicating complicated concepts and information to a wide range of audiences
Experience working with process improvement teams and streamlining processes as required and improving departmental efficiencies
Experience with Encoder Pro
Experience with IKA platform
Live in a location where there is a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
Proven solid analytical and research skills
Proven excellent written and verbal communication skills
Benefits
Comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401k contribution
Company
Optum
Optum is a healthcare company that provides pharmacy services, health care operations, and population health management. It is a sub-organization of UnitedHealth Group.
10001+ employees
H1B Sponsorship
Optum has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (648)
2024 (559)
2023 (620)
2022 (851)
2021 (593)
2020 (438)
Funding
Current Stage
Late StageLeadership Team
Daniel Castillo
Chief Executive Officer, Optum Care Delivery
J
Jay Green
Chief Financial Officer
Recent News
2025-11-29
2025-11-19
2025-11-07
Company data provided by crunchbase