Clinical Network Consultant assists in the development of operational framework focused on scalable and repeatable best practices as it relates to Risk Adjustment and GAPs in Care both within the CDQI Department and at the market level. This position supports and aligns planning to ensure the key strategic rationale for CDQI is delivered and the associated revenues and cost savings targets are realized. Will work closely with Network Development and CDQI leaders in all markets to ensure Enterprise initiatives related to Risk Adjustment and GAPs in care) are implemented and goals are met. The Clinical Network Consultant is imbedded in all markets to provide support and education to all market leaders, Providers and clinic staff. This position identifies, develops and implements simplification and automation to improve the Primary Care Provider (PCP), the market, and ultimately, the member experience.
Essential Job Functions
1. Educate practitioners/clinical staff and provide ongoing clinical guidance related to the Risk Adjustment process. Ensure all Market Leaders are utilizing established tools and are able to downstream this education in their prospective markets
2. Provide feedback to practioners, following review of charts and/or attestations related appropriate coding documentation.
3. Work collaboratively with market physician leadership in the development and management, project governance and detailed project plans as it relates to assigned market.
4. Collaborate with process improvement teams to design and implement work process flows to optimize practice efficiency in achieving CDQI objectives.
5. Partner with corporate leadership to identify the most beneficial options and assist in driving the completion of the selected option.
6. Partner with business owners to identify methods to execute upon the key strategic visions and lead the initiative to completion.
7. Work with corporate operations to develop program success metrics and ongoing performance metrics.
8. Provide strong leadership and judgment; effectively build and deepen relationships across assigned market.
9. Create a team-oriented work climate that enables professional development and encourages creative solutions and strategies, establishes collaboration and emphasizes quality and cost.
10. Provide leadership to and is accountable for the performance and direction through multiple layers of management and senior level professional staff.
11. Provides educational tools which may include presentations as assigned by management.
12. Review and update educational materials as approved by Leadership.
13. Perform Clinical Chart Audits as business needs dictate.
14. Perform Quality Audits to ensure error rate remains within industry standard.
15. Maintain compliance with Optum coding standards and CMS Risk Adjustment guidelines.
16. Performs all other related duties as assigned.
Minimum Required Education, Experience & Skills
- Bachelor’s Degree in Nursing required (Associate’s Degree or Nursing Diploma from accredited nursing school with 2 or more years of additional experience may be substituted in lieu of a bachelor’s degree)
- Current CT RN license
- CPC certification or proof that certification has been obtained within 9 months from the American Academy of Professional Coders required.
- 4-5 years of General Clinical experience required.
- Two years of clinical coding experience with strong attention to detail and a high level of accuracy.
- Knowledge of CMS-HCC model and guidelines along with ICD-9/10 and guidelines.
- Ability to speak and provide presentations and education to small and large groups alike
- Ability to work a flexible work schedule and travel to various provider offices
- Ability and willingness to travel as determined by business need.
- Effectively communicates complex ideas clearly and concisely to internal and external customers
- Able to create, build and maintain relationships in order to improve performance and establish trust and maintain creditability throughout the organization
- Demonstrates effective interpersonal, influence, collaboration and listening skills to address complex situations or issues with a high degree of integrity
- Possess a high tolerance to stress and the ability to handle difficult situations in a confident and diplomatic manner
- Provide leadership, organization and methodology to a project / operations team
- Excellent time management, organizational, and prioritization skills and ability to balance multiple priorities and make changes to work as the project needs dictate.
- MS Office Suite, moderate to advanced EXCEL and PowerPoint skills