The Medicare Consultant is responsible for providing expertise in the area of quality and risk adjustment coding for assigned provider groups. A Medicare Consultant will interface with operational and clinical leadership to assist in identification of operational and clinical best practices in maximizing recapture rates, understanding clinical suspects and monitoring of appropriate clinical documentation and quality coding. He / she will also coordinate implementation of programs designed to ensure all diagnoses are coded according to CMS and risk adjustment coding guidelines and conditions are properly supported by appropriate documentation in the patient chart. The Medicare Consultant will also ensure the providers understand the STARS CPTII coding requirements. This position will function in a matrix organization taking direction about job function from UHC and M&R but reporting directly to Optum Insight.
If you are located in the Knoxville, TN area, you will have the flexibility to telecommute* as you take on some tough challenges in this largely field-based role.
Assists providers in understanding the CMS-HC Risk Adjustment program as it relates to payment methodology and the importance of proper chart documentation of procedures and diagnosis coding
Monitors Stars quality performance data for providers and promotes improved healthcare outcomes
Utilizes analytics and identifies and targets providers for Medicare Risk Adjustment training and documentation/coding resources
Assists providers in understanding the Medical Condition Assessment Incentive Program and Medicare Stars quality and CMS - HCC Risk Adjustment driven payment methodology and the importance of proper chart documentation of procedures and diagnosis coding
Supports the providers by ensuring documentation supports the submission of relevant ICD -10 codes and CPTII procedural information in accordance with national coding guidelines and appropriate reimbursement requirements
Routinely consults with medical providers to clarify missing or inadequate record information and to determine appropriate diagnostic and procedure codes
Ensures member encounter data (services and disease conditions) is being accurately documented and relevant procedural codes and all relevant diagnosis codes are captured.
Provides thorough, timely, and accurate consultation on ICD-10 and/or CPT 2 codes by providers or practice clinical consultants
Refers inconsistent or incomplete patient treatment information/documentation to coding quality analyst, provider, supervisor, or individual department for clarification/additional information for accurate code assignment
Provides ICD10 - HCC coding training to providers and appropriate staff.
Develops and presents coding presentations and training to large and small groups of clinicians, practice managers and certified coders developing training to fit specific provider's needs
Develops and delivers diagnosis coding tools to providers
Trains physicians and other staff regarding documentation and billing and coding, and provides feedback to physicians regarding documentation practices
Educates providers and staff on coding regulations and changes as it relates to Quality and Risk Adjustment to ensure compliance with state and federal regulations
Performs analysis and provides formal feedback to providers on a regularly scheduled basis
Provides measurable, actionable solutions to providers that will result in improved accuracy for documentation and coding practices
Reviews selected medical documentation to determine if assigned diagnosis, procedures codes, and ICD-10 codes are appropriately assigned
Assesses adequacy of documentation and queries providers to obtain additional medical record documentation or to clarify documentation to ensure accurate and appropriate coding
Collaborates with doctors, coders, facility staff, and a variety of internal and external personnel on a wide scope of Risk Adjustment and Quality education efforts
3+ years of clinic or hospital experience and / or managed care experience
Certified Risk Adjustment Coder AND/OR Certified Professional Coder with the American Academy of Professional Coders, with the requirement to obtain both certifications (CRC and CPC) within first year in position; CRC within 6 months of hire and CPC within 1 year of hire
Knowledge of ICD10
Intermediate level of proficiency in MS Office - Excel (pivot tables, excel functions), PowerPoint, and Word
Must be able to work effectively with common office software, coding software, EMR, and abstracting systems
Ability to travel regionally up to 75% (primarily day trips depending on region)
1+ years of experience in Risk Adjustment and HEDIS/Stars
Bachelor’s degree (preferably in Healthcare or relevant field)
Demonstrated knowledge and understanding of ICD and CPT coding principles as recommended by the American Health Information Management Association coding competencies, and as normally demonstrated by certification by the American Academy of Professional Coders
Knowledge of EMR for recording patient visits
Previous experience in management position in a physician practice
1+ year(s) of experience coding in health care facility
Knowledge of billing/claims submission and other related actions
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- All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
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.
ICD-9, ICD-10, CPC, Coder, Trainer, Healthcare, Managed Care, Provider, Medicare, Medicare Risk Adjustment. LPN, RN, CRC, Knoxville, TN, Tennessee