Medicare Consultant - Field Based - Telecommute in SC (Columbia, Greensboro, Greenville)

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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.

If you are located in Greensboro, Greenville or Columbia, SC (or surrounding areas), 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 model as it relates to payment methodology and the importance of proper chart documentation and coding of procedures (e.g. Annual Care Visits or 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:
  • Certified Risk Adjustment Coder (CRC via AAPC) or either: Certified Professional Coder (CPC via AAPC) or Certified Coding Specialist - Physician-based (CCS-P via AHIMA)
  • with the requirement to obtain both certifications within first year in position (CRC within 6 months of hire and CPC within 1 year of hire, if not currently CPC or CCS-P)
  • 1+ years of experience in Risk Adjustment
  • Knowledge of ICD-10-CM and CPT II coding
  • Demonstrate a level of knowledge, skill and understanding of ICD-10-CM and CPT coding principles consistent with certification by AAPC or AHIMA
  • Advanced proficiency in MS Office (Excel, PowerPoint and Word)
  • Able to work effectively with common office software, coding software, EMR and abstracting systems

Preferred Qualifications:
  • Bachelor's degree in Healthcare or relevant field
  • 3+ years of clinic or hospital experience and/or managed care experience
  • 1+ years of coding performed at a health care facility
  • Experience in HEDIS/Stars
  • Experience in management or coding position in a provider primary care practice
  • Experience giving group presentations
  • Knowledge of EMR for recording member visits
  • Knowledge of billing or claims submission and other related actions
  • Ability to develop long-term relationships
  • Good work ethic, desire to succeed, self-starter
  • Solid business acumen and analytical skills
  • Ability to deliver training materials designed to improve provider compliance
  • Ability to use independent judgment, and to manage and impart confidential information
  • Excellent oral & written communication skills


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: Medicare Consultant, Field Based, Telecommute, Telecommuting, Telecommuter, Work From Home, Work At Home, Remote, Greensboro, Greenville, Columbia, SC, South Carolina

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