Requisition Number: 2204575
Job Category: Network Management
Primary Location: Nashville, TN
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
The Practice Consultant is responsible for program implementation and provider performance management which is tracked by designated provider metrics, inclusive minimally of 4 STAR gap closure and coding accuracy demonstrating full assessment and suspect closure. The person in this role is expected to work directly with care providers to build relationships, ensure effective education and reporting, proactively identify performance improvement opportunities through analysis and discussion with subject matter experts; and influence provider behavior to achieve needed results. The person will review charts (paper and electronic – EMR), identify gaps in care and open suspect opportunities, and educate providers and offices to ensure they are coding to the highest specificity for both risk adjustment and quality reporting. Work is primarily performed at physician practices on a daily basis.
NOTE: Qualified candidates must live in the Nashville TN Regional Area to be considered (daily travel is required in this area)
If you have the ability to live in the Nashville, TN regional area to conduct daily travel requirements you will have the flexibility to work remotely* as you take on some tough challenges.
- Functioning independently, travel across assigned territory to meet with providers to discuss UHC and Optum tools and UHC incentive programs for both risk adjustment and quality reporting, focused on improving the quality of care for Medicare Advantage Members
- Establish positive, long-term, consultative relationships with physicians, medical groups, IPAs and ACOs
- Develop comprehensive, provider-specific plans to increase their HEDIS performance, facilitate risk adjustment suspect closure and improve their outcomes
- Access PCOR to identify risk adjustment opportunities and utilize other available reporting sources including but not limited to (InSite, Spotlight, Doc360, Provider Scorecard, CPT II Report) to analyze data and prioritize gap and suspect closure, identify trends and drive educational opportunities
- Conduct chart review quarterly and provide timely feedback to provider to improve reporting on a go forward basis.
- Conduct additional chart reviews such as a quarterly post-visit ACV review and various focused progress notes reviews with provider feedback to improve documentation and coding resulting in improved gap and suspect closure
- Coordinates and provides ongoing strategic recommendations, training and coaching to provider groups on program implementation and barrier resolution.
- Training will include Stars measures (HEDIS/CAHPS/HOS/medication adherence), coding for quality care (CPT II) and exclusions (ICD-10-CM), risk adjustment coding practices (ICD-10-CM), and Optum program administration including use of plan tools, reports and systems
- Lead regular Stars and risk adjustment specific JOC meetings with provider groups to drive continual process improvement and achieve goals
- Provide reporting to health plan leadership on progress of overall performance, MAPCPi, MCAIP, gap closure, and use of virtual administrative resources
- Facilitate/lead monthly or quarterly meetings, as required by plan leader, including report and material preparation
- Collaborates and communicates with the member’s health care and service with our interdisciplinary delivery team to coordinate the care needs for the member
- Partner with providers to engage in UnitedHealthcare member programs such as HouseCalls, clinic days, Navigate4Me
- Weekly commitment of 60% travel for business meetings (including client/health plan partners and provider meetings) and 40% remote work
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Years of post-high school education can be substituted/is equivalent to years of experience
- Certified Risk Adjustment Coder (CRC via AAPC) or either: Certified Professional Coder (CPC via AAPC) or Certified Coding Specialist – Physician-based (CCS-P via AHIMA)
- with the requirement to obtain both certifications within first year in position (CRC within 6 months of hire and CPC within 1 year of hire, if not currently CPC or CCS-P)
- 5+ years of healthcare industry experience
- 1+ years of provider facing experience
- Microsoft Office experience including Excel (specifically having exceptional analytical and data representation expertise)
- Proven knowledge of Medicare Advantage including Stars and Risk Adjustment
- Proven relationship building skills with clinical and non-clinical personnel
- Knowledge of ICD-10-CM and CPT II coding
- Proven ability to weekly commitment of 75% travel for business meetings (including client/health plan partners and provider meetings) and 25% remote work
- Proven ability to provide proof of a valid Driver’s License and current Auto Insurance
- Live in the Nashville TN Regional Area to conduct daily travel requirements
- Registered Nurse
- Experience working for a health plan and/or within a provider office
- Experience with network and provider relations/contracting
- Experience retrieving data from EMRs (electronic medical records)
- Experience in management or coding position in a provider primary care practice
- Demonstrate a level of knowledge, skill and understanding of ICD-10-CM and CPT coding principles consistent with certification by AAPC or AHIMA
- Knowledge base of clinical standards of care, preventive health, and Stars measures
- Knowledge of billing or claims submission and other related actions
- Proven ability to deliver training materials designed to improve provider compliance
- Proven ability to use independent judgment, and to manage and impart confidential information
- Proven good work ethic, desire to succeed, self-starter
- Proven excellent oral & written communication skills
- Proven problem-solving skills
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
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