Job Description

WellMed, part of the Optum family of businesses, is seeking a Registered Nurse to join our team in San Antonio, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

The Sr. Clinical Coding Nurse Consultant will drive consistent, efficient processes and share best practices in a collaborative effort with Providers and Market Team, designed to facilitate achievement of goals set for HCC Ratio, HCC Covered Ratio, and HCC Percent Covered. The Sr. Clinical Coding Nurse Consultant will drive Risk Adjustment improvement initiatives, develop recommendations for Risk Adjustment remediation plans and create tools and databases to capture relevant data for assigned markets to achieve corporate and market specific Risk Adjustment goals and initiatives. This position will work collaboratively with each regional/market team and their leadership in a matrix relationship. This position will provide direction and guidance to Medical Coding Analysts, as well as cross functional team members within their respective Markets pertaining to Risk Adjustment. 

This is a Hybrid/office-based position located near Interstate Highway I-10 West, near West Frontage Road just past The Rim Shopping Center/Ferrari Dealership, 78257. 25% position travel as determined by the business.

Primary Responsibilities:

• Develop and implement market business plans to motivate providers to engage in improving Risk Adjustment metrics
• Provide analytical interpretation of Risk Adjustment reporting including, Executive Summaries, HCC Ratio, Disagree and Resolution rates, and FaxBack reporting to plan and provider groups
• Subject Matter Expert (SME) for all Risk Adjustment related activities within their assigned market(s) working within a matrix relationship which includes DataRAP operations and Regional/Market operations
• Assist in developing of training and analytical materials for Risk Adjustment
• Oversee DataRAP training and education delivery for Mega Groups via Provider education sessions and Physician Business Meetings / JOCs
• Lead Weekly, Monthly, Bi-monthly, Quarterly, and/or Annual Business Review meetings related to Risk Adjustment activities which summarize provider group performance and market performance as requested by or required by Market leadership
• Analyze and evaluate provider group structure and characteristics, provider group/provider office operations and personnel to identify the most effective approaches and strategies related to Risk Adjustment
• Analyze Provider and Group performance regarding Risk Adjustment and Focus on Care (FOC) to determine areas of focus or improvement opportunities
• Develop solution-based, user friendly initiatives to support practice success
• Oversee market specific chart retrieval and review of PCP, Hospital, and Specialist records
• Work with DataRAP Senior Leadership on identified special projects

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:

• Bachelor’s degree in Nursing (Associate’s degree or Nursing Diploma from accredited nursing school with 2+ years of additional experience may be substituted in lieu of a bachelor’s degree) and current RN license in good standing
• CPC certification or proof that certification has been obtained within 9 months from date of hire from the American Academy of Professional Coders 
• 5+ years of associated nursing experience within health care industry
• 1+ years of familiarization with ICD10 codes 
• Professional experience persuading changes in behavior
• Solid knowledge of the Medicare market, products and competitors
• Knowledge base of clinical standards of care and preventative health measures
• Proven ability and willingness to travel (locally and non-locally) as determined by business needs

Preferred Qualifications:

• Undergraduate degree 
• Experience in managed care working with network and provider relations
• Additional Medical chart review experience
• Medical/clinical background 
• Knowledge of CMS HCC Model and Guidelines along with ICD 10 Guidelines
• Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels
• Proven ability to solve process problems crossing multiple functional areas and business units
• Proven solid presentation skills and relationship building skills with clinical/non-clinical personnel
• Proven solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
• Proven good business acumen, especially as it relates to Medicare
• Proven MS Office Suite, moderate to advanced EXCEL and PowerPoint skills

Physical & Mental Requirements:

• Ability to push or pull heavy objects using pounds of force
• Ability to stand for extended periods of time
• Ability to properly drive and operate a company vehicle

In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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