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Medicare Consultant - Columbia, SC at UnitedHealth Group

Medicare Consultant - Columbia, SC

UnitedHealth Group Work From Home, TX (Onsite) Full-Time

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. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life's best work.(sm)

The Medicare Consultant is responsible for providing expertise in the area of primarily risk adjustment coding for provider clients. The Medicare Consultant supports the work of the Practice Performance Manager in discussing coding for quality performance reporting.  A Medicare Consultant will interact with operational and clinical leadership to assist in identification of operational and clinical best practices in understanding and assessing chronic condition suspects, appropriate clinical documentation and accurate coding.  The Medicare Consultant will facilitate implementation of programs designed to ensure all diagnoses are supported by appropriate documentation in the member chart and correct coding according to the CMS, the CDC and official risk adjustment coding guidelines. The Medicare Consultant will also ensure that providers understand CPT II coding for the CMS Medicare Advantage Star Ratings program.  This position functions in a matrix organization taking direction about job function from UHC M&R but reporting directly to OptumInsight.  This role will be 40% telecommute, and 60% local travel.  

If you live within an hour of Columbia, SC, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

  • Assist providers in understanding the CMS-HCC risk adjustment model as it relates to payment methodology and the importance of proper chart documentation and coding of procedures (e.g. Annual Care Visits [ACVs]) and diagnoses

  • Assist providers in understanding coding for the CMS Medicare Advantage Star Ratings quality program - CPT II coding, the coding for Frailty and Advanced Illness Exclusions and any future coding topics, whenever applicable to a measure

  • Monitor appropriate chart documentation and consult with providers on correct coding practices that promotes improved healthcare outcomes

  • Utilize analytics to identify providers with the greatest opportunity for improved reporting, for Medicare Risk Adjustment and documentation and coding training utilizing UHC and Optum documentation/coding resources

  • Assist providers in understanding the MCAIP incentive program, the CMS-HCC risk adjustment model and payment methodology, and the CMS Medicare Advantage Star Ratings program and the importance of proper chart documentation and coding of certain procedures (e.g. ACVs), diagnoses and quality reporting codes

  • Support providers by ensuring documentation requirements are met for the submission of relevant ICD-10-CM codes and CPT II quality information in accordance with federal documentation and coding guidelines and appropriate UHC requirements

  • Routinely conduct chart reviews and consult with providers to provide feedback regarding missing or inadequate medical record documentation and to provide coding education

  • Ensure that member encounter data are being accurately documented and that correct procedure codes (e.g. AVCs) and all relevant diagnosis codes are captured

  • Provide timely, thorough, and accurate consultation on ICD-10-CM and/or CPT II codes to providers or practice teams (e.g. coders, billers, population health staff)

  • Identify inconsistent or incomplete member treatment information/documentation for coding quality analyst, provider, supervisor or individual department for clarification/additional information or education that leads to accurate code assignment

  • Provide ICD-10-CM and CPT II coding training to providers and appropriate staff (not including CEUs) (Note:  MCs who are Approved Trainers can provide CEUs)

  • Understand and present to providers Optum and UHC material related diagnosis coding, quality reporting and UHC incentive programs

  • Train providers and other staff regarding documentation and coding as well as provide feedback to providers regarding their documentation and coding practices

  • Educate providers and staff on coding regulations and changes as they pertain to risk adjustment and quality reporting to ensure compliance with federal and state regulations

  • Review selected medical record documentation to determine appropriate diagnosis coding and quality reporting coding per CMS, CDC & AMA documentation, and coding guidelines

  • Provide actionable, measurable solutions to providers that will result in improved documentation and coding accuracy, optimal suspect closure, and quality gap closure

  • Collaborate with providers, coders, facility staff and a variety of internal and external personnel on wide scope of risk adjustment and quality reporting education efforts

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.

Required Qualifications:

  • Currently hold some type of medical coding certification  

  • CRC (Certified Risk Adjustment Coder), or ability to obtain within 6 months of hire  

  • CPC (Certified Professional Coder), or ability to obtain within 12 months of hire  

  • 3+ years of experience in a clinic, a hospital, and/or in managed care  

  • 1+ years of experience in Risk Adjustment  

  • Knowledge of ICD-10-CM and CPT-II coding  

  • Proficiency in MS Office (Word, Excel, and PowerPoint)  

  • Ability to work effectively with coding software, EMR’s, and abstracting systems  

  • Ability to accommodate 60% local travel to meet with client/health plan partners and providers  

Preferred Qualifications:

  • Bachelor’s degree  

  • Experience with HEDIS/STARS  

  • Experience presenting to groups  

  • Coding experience at a healthcare facility  

  • Experience using EMR’s to record member visits  

  • Experience in management, or Coder experience in a provider’s primary care practice  

  • Knowledge of claims billing and/or claims submission processes  

  • Understanding of ICD-10-CM and CPT coding principles consistent with AAPC/AHIMA certifications  

  • Ability to deliver training materials designed to improve provider compliance  

  • High work ethic, desire to succeed, and self-starter, with solid business acumen and analytical skills  

  • Ability to develop long-term relationships, use independent judgment, and to manage confidential information  

  • Excellent verbal and written communication skills  

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

•All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: 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.

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