Medicare Risk Adjustment & Coding Consultant - Field Based in Tallahassee, FL / Pensacola, FL Region

UHG Pensacola, FL

About the Job

The Medicare Consultant is responsible for providing expertise in the area of quality and risk adjustment coding for provider clients. 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. Medicare Consultant 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 that providers understand HEDIS CPTII coding requirements. This position will function in a matrix organization taking direction about job function from UHC M&R but reporting directly to OptumInsight.


If you are located in the Tallahassee / Pensacola, FL region, you will have the flexibility to telecommute* as you take on some tough challenges.


Primary Responsibilities:

  • Assist providers in understanding the CMS-HCC Risk Adjustment program as it relates to payment methodology and the importance of proper chart documentation of procedures and diagnoses coding. Understand Medicare Stars quality program utilizing analytics and identifies and targeted providers
  • Monitor Stars quality performance data for providers and promotes improved healthcare outcomes
  • Utilize analytics and identifies targeted providers for Medicare Risk Adjustment training and documentation/coding resources
  • Assist providers in understanding the MCAIP incentive program, Medicare Stars quality and CMS -HCC Risk Adjustment driven payment methodology with importance of proper chart documentation of procedures and diagnosis coding
    Supports the Providers by ensuring documentation requirements are met for the submission of relevant ICD -10 codes and CPTII procedural information in accordance with national coding guidelines and appropriate reimbursement requirements
  • Routinely consult with medical providers to clarify missing or inadequate record information to determine appropriate diagnostic and procedure codes
  • Ensure member encounter data (services and disease conditions) is being accurately documented and relevant procedural codes as well as all relevant diagnosis codes are captured
  • Provide thorough, timely and accurate consultation on ICD-10 and/or CPTII codes to providers or practice teams
  • Refer inconsistent or incomplete patient treatment information/documentation to coding quality analyst, provider, supervisor or individual department for clarification/additional information for accurate code assignment
  • Provide ICD10 - HCC coding training to providers and appropriate staff (not including CEUs)
  • Develop and deliver Optum diagnosis coding tools to providers
  • Train Providers and other staff regarding documentation, billing and coding and provides feedback to Providers 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 regularly scheduled basis
  • Provides measurable, actionable solutions to Providers that will result in improved documentation accuracy
  • Review selected medical documentation to determine appropriate diagnoses, procedures codes and ICD-10 condition are coded per CMS coding guidelines
  • Assess adequacy of documentation and queries providers to obtain additional medical record documentation or to clarify documentation to ensure accurate and appropriate coding
  • Collaborates with providers, coders, facility staff and a variety of internal and external personnel on wide scope of Risk Adjustment and Quality education efforts

Required Qualifications:

  • 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)
  • Minimum 3+ years of clinic or hospital experience and / or managed care experience
  • Knowledge of ICD10-CM coding
  • Advanced proficiency in MS Office (Excel, PowerPoint and Word)
  • Must be able to work effectively with common office software, coding software, EMR and abstracting systems
  • Ability to travel regionally approximately 75%


Preferred Qualifications:

  • Bachelor’s degree in health care or relevant field
  • 1+ years experience in Risk Adjustment and HEDIS / Stars
  • Demonstrate a level of knowledge and understanding of ICD10-CM and CPT coding principles consistent with certification by the American Academy of Professional Coders
  • Knowledge of EMR for recording patient visits
  • Experience in management position in a provider primary care practice
  • Experience coding performed at a health care facility
  • Knowledge of billing / claims submission and other related actions

Building diverse, high quality provider networks is creating greater access to health care and improving the lives of millions. Join us. Learn more about how you can start doing your life's best work.(sm)

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world?s large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)


*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.



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.



Job Keywords: ICD-10, CPC, Coder, Trainer, Healthcare, Managed Care, Provider, Medicare, Medicare Risk Adjustment, Tallahassee, FL, Pensacola, FL, Florida