Registered Nurse RN Senior Clinical Coding Nurse Houston Texas - Full-time / Part-time

Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.   

The Sr. Clinical Coding RN 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. 

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

This is a Hybrid / Field Base position requiring travel in the Houston area

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 Degree or Nursing Diploma from accredited nursing school with 2+ years of additional experience may be substituted in lieu of a bachelor’s degree)
• Current unrestricted Texas RN license or compact license
• CPC certification or proof that certification has been obtained within 9 months from the American Academy of Professional Coders
• 5+ years of associated business experience with health care industry
• 1+ years of ICD-9, ICD10 coding experience
• 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
• Knowledge of CMS HCC Model and Guidelines along with ICD 10 Guidelines
• 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 highly desirable
• MS Office Suite, moderate to advanced Excel and PowerPoint skills
• 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