Senior Clinical Coding Nurse Consultant
23 hours ago
We are seeking a highly skilled Senior Clinical Coding Nurse Consultant to join our team in Jacksonville, FL. As a member of our Optum Care Delivery team, you will play a critical role in driving consistent, efficient processes and sharing best practices with Providers and Market Team to achieve goals set for HCC Ratio, HCC Covered Ratio, and HCC Percent Covered.
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 that 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 health care industry
- 1+ years of familiarization with ICD10 codes
- Professional experience persuading changes in behavior
- Proven solid knowledge of the Medicare market, products, and competitors
- Demonstrated 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
- Undergraduate degree
- Experience in managed care working with network and provider relations
- Knowledge of CMS HCC Model and Guidelines along with ICD 10 Guidelines
- Solid 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
- 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
- Medical/clinical background highly desirable
- MS Office Suite, moderate to advanced EXCEL and PowerPoint skills
- Additional Medical chart review experience
- Ability to lift up to 10 pounds
- Ability to sit for extended periods of time
- Ability to use fine motor skills to operate equipment and/or machinery
- Ability to receive and comprehend instructions verbally and/or in writing
- Ability to use logical reasoning for simple and complex problem solving
We are 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.
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