Medicare Consultant – MCAIP – Remote in Chicago

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.  

The Medicare Consultant provides specialized expertise in risk adjustment coding, supporting provider clients and collaborating closely with Practice Performance Managers to enhance quality performance reporting. This role engages with operational and clinical leadership to identify best practices in chronic condition assessment, clinical documentation, and accurate coding. The Consultant facilitates the implementation of programs that ensure diagnoses are properly documented and coded in compliance with CMS, CDC, and official risk adjustment guidelines. Additionally, the Consultant educates providers on CPT II coding requirements for the CMS Medicare Advantage Star Ratings program. Operating within a matrixed environment, this position receives direction from UHC M&R while reporting directly to Optum Insight.

If you are located in Chicago, IL, you will have the flexibility to work remotely* as you take on some tough challenges. Candidates must live in the area to perform onsite visits if needed.

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 [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 or Certified Professional Coder with AAPC 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)
• 3+ years of clinic or hospital experience and/or managed care experience
• 1+ years of experience in Risk Adjustment
• Proven knowledge of ICD-10-CM and CPT II coding
• Intermediate or Advanced proficiency in MS Office – specifically Excel (Pivot Tables, VLOOKUP), PowerPoint (Creating/Formatting Presentations), and Word
• Experience with communication/presentation to stakeholders and leaders
• Ability to work effectively with common office software, coding software, EMR and abstracting systems
• Ability to provide proof of a valid, unrestricted Driver’s License and current Auto Insurance
• Ability to travel up to 75% 
• Reside in Chicago, IL

Preferred Qualifications:

• 1+ years of experience in Account Management or Sales, preferably in healthcare or insurance industry
• 1+ years of coding performed at a health care facility 
• Demonstrated knowledge, skill and understanding of ICD-10-CM and CPT coding principles consistent with certification by AAPC 
• Experience in HEDIS/Stars  
• Proven knowledge of EMR for recording member visits
• Experience in management or coding position in a provider primary care practice
• Proven knowledge of billing or claims submission and other related actions
• Ability to deliver training materials designed to improve provider compliance
• Ability to use independent judgment, and to manage and impart confidential information

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

The salary range for this role is $89,800 to $176,700 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.