RN Clinical Coding Nurse Consultant WellMed San Antonio Texas
UnitedHealth Group
- San Antonio, TX
- Permanent
- Full-time
- 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 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 hire date from the American Academy of Professional Coders
- 3+ years associated business experience with health care industry
- 1+ years of ICD-9, ICD10 coding experience
- Professional experience persuading changes in behavior
- Knowledge of CMS HCC Model and Guidelines along with ICD 10 Guidelines
- Knowledge base of clinical standards of care and preventative health measures
- Solid knowledge of the Medicare market, products and competitors
- 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
- MS Office Suite, moderate to advanced EXCEL and PowerPoint skills
- Proven 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
- Demonstrated ability to solve process problems crossing multiple functional areas and business units
- 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
- Ability to push or pull heavy objects using up to pounds of force
- Ability to stand for extended periods of time
- Ability to properly drive and operate a company vehicle