Sr. Clinical Coding Nurse Consultant - Hybrid in San Antonio, TX
About The Position
The Sr. Clinical Coding Nurse Consultant drives consistent, efficient Risk Adjustment processes and shares best practices in collaboration with providers and Market Teams to support goals for HCC Ratio, HCC Covered Ratio, and HCC Percent Covered. The role leads Risk Adjustment improvement initiatives, recommends remediation plans, and creates tools and databases to capture relevant market data. It works collaboratively with regional and market teams and leadership in a matrix relationship, and provides direction and guidance to Medical Coding Analysts and cross-functional team members on Risk Adjustment matters. This is a hybrid role based in San Antonio, Texas, working three to four days per week in the office, from 8:00 a.m. to 5:00 p.m. CST. Local and non-local travel may be required according to business needs. The position involves provider engagement, performance analysis, training and education, business reviews, and oversight of market-specific chart retrieval and review.
Requirements
- Bachelor’s degree in Nursing and a current RN license in good standing; an Associate’s degree in Nursing or Nursing Diploma from an accredited nursing school plus 2+ additional years of experience may substitute for the bachelor’s degree.
- CPC certification, or proof that certification will be obtained within 9 months, from the American Academy of Professional Coders.
- 5+ years of associated nursing experience in the healthcare industry.
- 1+ year of experience with ICD-10 codes.
- Professional experience persuading changes in behavior.
- Solid knowledge of the Medicare market, products, and competitors.
- Knowledge of clinical standards of care and preventative health measures.
- Ability and willingness to travel locally and non-locally as determined by business needs.
- Ability to lift up to 10 pounds, sit for extended periods, and 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.
Nice To Haves
- Experience in managed care working with network and provider relations.
- Knowledge of the CMS HCC Model and Guidelines and ICD-10 Guidelines.
- Strong presentation and relationship-building skills with clinical and non-clinical personnel.
- Ability to interact with medical staff, peers, and internal company staff at all levels.
- Moderate to advanced MS Office Suite, Excel, and PowerPoint skills.
- Ability to solve process problems across multiple functional areas and business units.
- Strong problem-solving skills, including analyzing problems, drawing relevant conclusions, and devising and implementing an appropriate plan of action.
- Excellent business acumen, especially as it relates to Medicare.
- Medical or clinical background.
- Undergraduate degree.
- Additional medical chart review experience.
Responsibilities
- Develop and implement market business plans to motivate providers to improve Risk Adjustment metrics.
- Interpret Risk Adjustment reporting, including Executive Summaries, HCC Ratio, Disagree and Resolution rates, and FaxBack reporting, for plan and provider groups.
- Serve as the subject matter expert for Risk Adjustment activities in assigned markets, coordinating with DataRAP and Regional/Market operations.
- Assist in developing Risk Adjustment training and analytical materials.
- Oversee DataRAP training and education for Mega Groups through provider education sessions and Physician Business Meetings/JOCs.
- Lead business review meetings at weekly, monthly, bi-monthly, quarterly, and/or annual intervals to summarize provider-group and market performance as requested or required by Market leadership.
- Analyze provider-group structures and characteristics, office operations, and personnel to determine effective Risk Adjustment strategies.
- Analyze provider and group performance regarding Risk Adjustment and Focus on Care to identify areas for focus and improvement.
- Develop solution-based, user-friendly initiatives to support practice success.
- Oversee market-specific chart retrieval and review for PCP, hospital, and specialist records.
- Work with DataRAP Senior Leadership on identified special projects.
- Provide direction and guidance to Medical Coding Analysts and cross-functional team members on Risk Adjustment matters.
Benefits
- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401(k) contribution
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What This Job Offers
Job Type
Full-time
Career Level
Senior
