Senior Data Analyst - Payer Side - CMS, NCCI

Optum; Dadri; On-site; INR 1,500,000 - 2,100,000; Full time

Job summary

Optum is seeking a Senior Data Analyst on the Payer Side to lead clinical evaluation of FWA in US healthcare claims, interpreting CMS, NCCI, and LCD/NCD policies. The role requires deep CPT/HCPCS/ICD-10-CM knowledge and the ability to translate findings into payment integrity actions.

You'll collaborate with onshore clinical teams, mentor junior analysts, and drive analytics-driven PI programs while ensuring compliance with policies and contract guidelines.

Qualifications

• 8+ years in US healthcare payment integrity, coding, or claims review.
• Strong ability to translate clinical findings into payment actions.
• Expert knowledge of CPT, HCPCS, ICD-10-CM, DRG and billing.
• Experience interpreting CMS/NCCI policies and payer guidelines.
• Excellent leadership and communication skills.

Responsibilities

• Lead evaluation of FWA across US healthcare claims with coding expertise.
• Translate CMS, NCCI, and LCD/NCD policies into actionable insights.
• Act as SME for high‑risk coding patterns like DRG shifts and upcoding.
• Review complex scenarios including multi‑specialty billing.
• Mentor junior analysts on coding accuracy and policy interpretation.
• Collaborate with onshore clinical teams to align reviews.
• Define inclusion/exclusion logic with clinical justification.
• Support PI program initiatives and chart/claim reviews.

Skills

US healthcare knowledge

Clinical claims review

CPT/HCPCS/ICD-10-CM knowledge

Policy interpretation

Communication with stakeholders

Team mentorship

Tools

SQL

Tableau

Job description

Improve the lives of others while Caring. Connecting. Growing together.

Job Description - Senior Data Analyst - Payer Side - CMS, NCCI (2372152)

Senior Data Analyst - Payer Side - CMS, NCCI - 2372152

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:

• Lead clinical evaluation of fraud, waste, and abuse (FWA) scenarios across US healthcare claims with deep coding and policy expertise
• Drive interpretation of complex reimbursement policies (CMS, NCCI, LCD/NCD) and translate into actionable payment integrity insights
• Act as a clinical subject matter expert (SME) for high-risk coding patterns including DRG shifts, E/M upcoding, and modifier misuse
• Evaluate advanced clinical scenarios including multi-specialty billing, inpatient vs outpatient coding differences, and bundled services
• Provide clinical thought leadership in identifying emerging payment integrity risks across provider types and specialties
• Collaborate closely with onshore clinical teams to align on policy interpretation and review standards
• Own clinical validation strategy ensuring high true positive rates and minimal provider abrasion
• Support strategic initiatives to enhance clinical rigor in analytics-driven PI programs
• Perform deep clinical review of professional and institutional claims to detect FWA and coding inaccuracies
• Interpret CPT, HCPCS, ICD-10-CM, DRG, modifiers, and revenue codes in highly complex billing scenarios
• Apply advanced CMS policies, NCCI edits, MUEs, and medical necessity rules for claim validation
• Lead development of clinically robust rules covering unbundling, upcoding, duplicate billing, and non-covered services
• Validate rule outputs through detailed chart/claim review and clinical reasoning
• Define inclusion/exclusion logic with strong clinical justification and payer alignment
• Mentor junior analysts on coding accuracy, policy interpretation, and clinical review techniques
• Partner with analytics teams to ensure accurate clinical translation into data models and outputs
• 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:

• 8+ years of experience in US healthcare payment integrity, coding, or clinical claims review
• Solid experience interpreting CMS manuals, NCCI policies, LCD/NCD, and payer guidelines
• Experience reviewing complex specialties (surgery, inpatient DRG, E/M, radiology, etc)
• Expert-level knowledge of CPT, HCPCS, ICD-10-CM, DRG, modifiers, and billing practices
• Deep understanding of medical necessity, diagnosis-procedure relationships, and documentation requirements
• Proven solid ability to translate clinical findings into business and payment integrity actions
• Proven excellent communication skills for leadership and stakeholder discussions

Preferred Qualifications:

• Experience in leading PI initiatives or large-scale FWA programs
• Experience working with clinical SMEs, auditors, and policy teams
• Experience creating audit-ready documentation and provider rationale
• Leadership or mentoring experience within analytics or PI teams
• Exposure to claim audits, DRG validation, and clinical documentation review
• Solid knowledge of Medicare Advantage and commercial payer nuances
• Familiarity with analytics tools (SQL/Tableau) to validate outputs (not mandatory)
• Demonstrated ability to drive concept ideation and clinical strategy for PI programs

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.

UnitedHealth Group is committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities. If you need special assistance or accommodation for any part of the application process, please call 1-866-566-8715 to be connected to Recruitment Services. Recruitment Services hours of operation are 7 a.m. to 7 p.m. CT, Monday through Friday.

UnitedHealth Group is a registered service mark of UnitedHealth Group, Inc. The UnitedHealth Group name with the dimensional logo, as well as the dimensional logo alone, are both service marks for the UnitedHealth Group, Inc.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.