RN Clinical Coding Nurse Consultant
3 weeks ago
We are seeking a highly skilled and experienced Senior Clinical Coding Nurse Consultant to join our team at Optum. As a key member of our organization, you will play a critical role in driving consistent and efficient processes, sharing best practices, and collaborating with providers and market teams to achieve corporate and market-specific goals.
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.
- Bachelor's degree in Nursing (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 date of hire from the American Academy of Professional Coders.
- 5+ years associated nursing experience within the healthcare industry.
- 1+ years of familiarization with ICD10 codes.
- 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.
- Proven ability and willingness to travel (locally and non-locally) as determined by business needs.
- Undergraduate degree.
- Experience in managed care working with network and provider relations.
- Additional Medical chart review experience.
- Medical/clinical background.
- Knowledge of CMS HCC Model and Guidelines along with ICD 10 Guidelines.
- Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels.
- Proven ability to solve process problems crossing multiple functional areas and business units.
- Proven solid presentation skills and relationship building skills with clinical/non-clinical personnel.
- Proven solid problem-solving skills; the ability to analyze problems, draw relevant conclusions, and devise and implement an appropriate plan of action.
- Proven good business acumen, especially as it relates to Medicare.
- Proven MS Office Suite, moderate to advanced EXCEL and PowerPoint skills.
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