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
- Monitor quality activities to increase departmental accuracy and efficiency, including but not limited to planning, development, and implementation of improvement areas
- Review analysis of audit findings quality trends and noncompliance issues detected through auditing
- Collaborate with team supervisors to develop best practices for communicating areas of improvement
- Manage the implementation of proactive solutions to mitigate risk that will impact project quality
- Incorporate feedback from operational and QA reports to improve performance
- Assesses, evaluates, and addresses variance in production and key goals for operations
- Participates in team meetings / discussions of quality trends reported by team members
- 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 regard 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
Functional Competencies
GOM_ Plan / Implement / Manage Medical Coding Quality Programs and StrategiesDevelop and tailor quality improvement plans aligned with regulatory and payer requirementsAnalyze client contracts, coding guidelines, and payer policies to incorporate into operational plansSupport internal teams and external partners in resolving coding-related issues and ensuring accurate implementation of coding protocolsEstablish and monitor service level agreements (SLAs) for coding accuracy, turnaround time, and audit responsivenessIdentify and secure resources (e.g., certified coders, audit tools, training platforms) necessary for program successReview and optimize coding workflows to ensure compliance, efficiency, and scalabilityProvide expert guidance to cross-functional teams (e.g., coding, OpX, compliance) to ensure coding strategies are effectively implementedInterpret regulatory and contractual coding requirements to support accurate documentation and reimbursementGOM_Monitor / Evaluate Medical Coding Quality Program PerformanceCollect feedback from stakeholders to assess the effectiveness of coding quality initiativesMonitor coding accuracy, audit outcomes, and compliance metrics against SLAs and industry benchmarksCollaborate with internal teams (e.g., coding, OpX, compliance) to produce accurate performance reportsUtilize dashboards and scorecards to track coding quality trends and identify areas for improvementValidate and analyze coding data to ensure accuracy and completenessReview consolidated performance reports to identify gaps, recommend corrective actions, and explore opportunities for program expansionIntegrate coding performance insights into strategic planning and operational forecastingDelegate post-implementation tasks to ensure contractual and regulatory obligations are metAnalyze coding performance using key indicators (e.g., RADV, OIG auditsGOM_Build / Maintain / Manage Relationships with Coding Operations and Compliance StakeholdersDevelop a deep understanding of stakeholder roles across coding, compliance, clinical, and revenue cycle teamsProvide regular performance updates through scorecards and audit summariesLead recurring meetings (e.g., quality reviews, audit debriefs) to discuss coding accuracy, compliance issues, and improvement plansCreate and manage corrective action plans to address coding discrepancies and audit findingsConduct in-depth reviews with stakeholders to identify continuous improvement opportunitiesEnsure stakeholders are informed of updated coding guidelines, payer policies, and regulatory changesCollaborate with internal and external partners to develop coding strategies that support quality, compliance, and financial goals.GOM_Support / Develop / Ensure Compliance with Coding Policies, Procedures, and RegulationsMaintain up-to-date knowledge of coding standards (e.g., ICD-10, RA coding standards), payer guidelines, and regulatory requirements (e.g., CMS, OIG)Educate staff on coding policies, documentation standards, and regulatory updatesInterpret and communicate contractual and regulatory coding requirements to ensure complianceContribute to the development and revision of coding policies and proceduresEnsure staff access and utilize current coding resources and regulatory updatesTrack training completion and compliance with coding education requirementsMonitor and report coding compliance metrics (e.g., audit results, error trends) to internal and external stakeholdersGOM_Review / Manage / Drive Operations Efficiency, Quality, and Financial PerformanceLeverage stakeholder feedback to drive continuous improvement in coding quality and operational efficiencyEnsure adherence to coding-related business and contractual obligationsConduct end-to-end testing of coding workflows and systems to validate compliance and accuracyReview and test business continuity plans related to coding operationsUse analytics tools to identify opportunities for coding process optimizationDemonstrate understanding of budgeting and forecasting as it relates to coding resource allocation and audit planningAnalyze budget variances and recommend adjustments to support coding quality initiativesCollaborate with finance and compliance teams to forecast resource needs and support strategic planningAssign coding quality projects based on team capacity, expertise, and performance metricsValues Based Competencies
Integrity Value : Model and Ensure Ethical BehaviorComply with Applicable Laws, Regulations and PoliciesDemonstrate IntegrityRequire Integrity and Ethical Behavior from OthersCompassion Value : Deliver Value to CustomersMaximize Customer Growth and RetentionOptimize the Customer ExperienceRelationships Value : Lead and Develop PeopleBring in the Right TalentDevelop PeopleDrive Employee EngagementFoster Teamwork and CollaborationLearn and Develop SelfLeverage Diversity and InclusionRelationships Value : Communicate EffectivelyCommunicate with ImpactInfluence and NegotiateListen ActivelyPresent EffectivelyInnovation Value : Lead Change and InnovationDemonstrate Emotional ResilienceImplement Innovative SolutionsManage ChangePerformance Value : Drive Sound, Disciplined DecisionsApply Financial KnowledgeMake Decisions to Drive ActionPerformance Value : Drive High-Quality ExecutionCommunicate Clear DirectionDrive Operational ExcellenceManage ExecutionRequired Qualifications
13+ years of leadership experience, including managing large, cross-functional teams in healthcare operations12+ years of specialized expertise in medical coding, with a solid focus on Risk Adjustment coding standards, methodologies, and complianceProven experience in overseeing clinical case reviews and RA coding audits, ensuring accuracy, completeness, and adherence to regulatory guidelinesHands-on experience managing business operations related to :Risk Adjustment CodingClinical InvestigationsRX Revenue Cycle Management (RCM)Provider CodingDemonstrated ability to manage P&L responsibilities for business units, driving performance and cost optimizationSuccessfully led and scaled teams of 350+ FTEs, fostering a culture of quality, accountability, and continuous improvementSolid Project Management capabilities, including planning, execution, and delivery of strategic initiatives in coding quality and complianceAt 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.
Skills Required
Project Management, Medical Coding