Clinical Coding Nurse Consultant

7 days ago

Pflugerville, Texas, United States Optum Full time
Job Summary

We are seeking a highly skilled Clinical Coding Nurse Consultant to join our team at Optum. As a key member of our Risk Adjustment team, you will be responsible for driving consistent and efficient processes to improve Risk Adjustment metrics.

Key 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 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, summarizing 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 projects
Requirements
  • Bachelor's Degree in Nursing required (Associate's Degree or Nursing Diploma from accredited nursing school with 2+ years of additional experience may be substituted in lieu of a bachelor's degree) and current RN license in good standing
  • CPC certification or proof that certification has been obtained within 9 months from the American Academy of Professional Coders
  • 5+ years associated business experience with healthcare industry
  • 1+ years of ICD-9, ICD10 coding experience
  • Knowledge of CMS HCC Model and Guidelines along with ICD 10 Guidelines
  • Professional experience persuading changes in behavior
  • Solid 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
  • Medical/clinical background
  • Experience in managed care working with network and provider relations
  • Solid presentation skills and relationship building skills with clinical/non-clinical personnel
  • MS Office Suite, moderate to advanced EXCEL and PowerPoint skills
  • Additional Medical chart review experience
  • 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
  • Solid 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

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