Job Description

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)

The Sr. Clinical Coding Nurse Consultant will drive consistent, efficient processes and share best practices in a collaborative effort with Providers and Market Team, designed to facilitate achievement of goals set for HCC Ratio, HCC Covered Ratio, and HCC Percent Covered. The Sr. Clinical Coding Nurse Consultant will drive Risk Adjustment improvement initiatives, develop recommendations for Risk Adjustment remediation plans and create tools and databases to capture relevant data for assigned markets to achieve corporate and market specific Risk Adjustment goals and initiatives. This position will work collaboratively with each regional / market team and their leadership in a matrix relationship. This position will provide direction and guidance to Medical Coding Analysts, as well as cross functional team members within their respective Markets pertaining to Risk Adjustment.

Primary Responsibilities:

* Develop and implement market business plans to motivate providers to engage in improving Risk Adjustment metrics
* Provide analytical interpretation of Risk Adjustment reporting including, Executive Summaries, HCC Ratio, Disagree and Resolution rates, and FaxBack reporting to plan and provider groups
* Subject Matter Expert (SME) for all Risk Adjustment related activities within their assigned market(s) working within a matrix relationship which includes DataRAP operations and Regional / Market operations
* Assist in developing of training and analytical materials for Risk Adjustment
* Oversee DataRAP training and education delivery for Mega Groups via Provider education sessions and Physician Business Meetings / JOCs.
* Lead Weekly, Monthly, Bi-monthly, Quarterly, and / or Annual Business Review meetings related to Risk Adjustment activities which summarize provider group performance and market performance as requested by or required by Market leadership
* Analyze and evaluate provider group structure and characteristics, provider group / provider office operations and personnel to identify the most effective approaches and strategies related to Risk Adjustment
* Analyze Provider and Group performance regarding Risk Adjustment and Focus on Care (FOC) to determine areas of focus or improvement opportunities.
* Develop solution-based, user friendly initiatives to support practice success
* Oversee market specific chart retrieval and review of PCP, Hospital, and Specialist records
* Work with DataRAP Senior Leadership on identified special project

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

* Bachelor's Degree in Nursing required (Associate's Degree or Nursing Diploma from accredited nursing school with 2 or more years of additional experience may be substituted in lieu of a bachelor's degree) and current RN license in good standing required
* CPC certification or proof that certification has been obtained within 9 months from date of hire from the American Academy of Professional Coders required
* Minimum of 1+ year of familiarization with ICD10 codes
* Minimum of 5+ years associated nursing experience within a health care industry
* Professional experience persuading changes in behavior
* Strong knowledge of the Medicare market, products, and competitors
* Knowledge base of clinical standards of care and preventative health measures
* Ability and willingness to travel (locally and non-locally) as determined by business needs

Preferred Qualifications:

* Undergraduate degree
* Experience in managed care working with network and provider relations
* Strong presentation skills and relationship building skills with clinical / non-clinical personnel
* Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels
* Ability to solve process problems crossing multiple functional areas and business units
* Strong problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
* Good business acumen, especially as it relates to Medicare
* Medical / clinical background
* MS Office Suite, moderate to advanced EXCEL and PowerPoint skills
* Additional Medical chart review experience
* Professional experience persuading changes in behavior

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 350,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

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.

Job Keywords: RN, Registered Nurse, CPC, Coding , San Antonio, TX , Texas, Risk Adjustment, Medical Record Review, chart review, field, ICD-9, ICD-10, CPT