1 day old

Medicare Consultant – MCAIP - KY

UnitedHealth Group
Lexington, KY
  • Job Code
777610 Medicare Consultant MCAIP KY

Medicare Consultant – MCAIP - KY (777610)

Position Description

The more you do, the more you learn. And as you learn you find new doors opening that challenge you to bring your best. This specialist role with UnitedHealth Group will call on your knowledge, your energy and your commitment to making health care work more effectively for more people. We're driving ever higher levels of sophistication in how provider networks are composed and compensated. Your expertise in provider networks can help us build in the next phase of evolution. In this managerial role, you'll use your knowledge and analytical skills to help determine how clinical providers group up by specialty and service line. As you do, you'll discover the resources, backing and opportunities that you'd expect from a Fortune 5 leader.


The Medicare Consultant is responsible for providing expertise in the area of quality and risk adjustment coding for provider clients. A Medicare Consultant will interface with operational and clinical leadership to assist in identification of operational and clinical best practices in maximizing recapture rates, understanding clinical suspects and monitoring of appropriate clinical documentation and quality coding. Medicare Consultant will also coordinate implementation of programs designed to ensure all diagnoses are coded according to CMS and risk adjustment coding guidelines and conditions are properly supported by appropriate documentation in the patient chart. The Medicare Consultant will also ensure that providers understand HEDIS CPTII coding requirements. This position will function in a matrix organization taking direction about job function from UHC M&R but reporting directly to Optum Insight.


If you are located in Kentucky, 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 program as it relates to payment methodology and the importance of proper chart documentation of procedures and diagnoses coding. Understand Medicare Stars quality program utilizing analytics and identifies and targeted providers
  • Monitor Stars quality performance data for providers and promotes improved healthcare outcomes
  • Utilizes analytics and identifies targeted providers for Medicare Risk Adjustment training and documentation/coding resources
  • Assist providers in understanding the MCAIP incentive program, Medicare Stars quality and CMS -HCC Risk Adjustment driven payment methodology with importance of proper chart documentation of procedures and diagnosis coding
  • Supports the Providers by ensuring documentation requirements are met for the submission of relevant ICD -10 codes and CPTII procedural information in accordance with national coding guidelines and appropriate reimbursement requirements
  • Routinely consults with medical providers to clarify missing or inadequate record information to determine appropriate diagnostic and procedure codes
  • Ensures member encounter data (services and disease conditions) is being accurately documented and relevant procedural codes as well as all relevant diagnosis codes are captured
  • Provides thorough, timely and accurate consultation on ICD-10 and/or CPTII codes to providers or practice teams
  • Refers inconsistent or incomplete patient treatment information/documentation to coding quality analyst, provider, supervisor or individual department for clarification/additional information for accurate code assignment
  • Provides ICD10 - HCC coding training to providers and appropriate staff (not including CEUs)
  • Develops and delivers Optum diagnosis coding tools to providers
  • Trains Providers and other staff regarding documentation, billing and coding and provides feedback to Providers regarding documentation practices
  • Educates Providers and staff on coding regulations and changes as it relates to Quality and Risk Adjustment to ensure compliance with state and federal regulations
  • Performs analysis and provides formal feedback to Providers on regularly scheduled basis
  • Provides measurable, actionable solutions to Providers that will result in improved documentation accuracy
  • Reviews selected medical documentation to determine appropriate diagnoses, procedures codes and ICD-10 condition are coded per CMS coding guidelines
  • Assesses adequacy of documentation and queries providers to obtain additional medical record documentation or to clarify documentation to ensure accurate and appropriate coding
  • Collaborates with providers, coders, facility staff and a variety of internal and external personnel on wide scope of Risk Adjustment and Quality education efforts

Required qualifications:

  • Bachelor’s degree (preferably in Healthcare or relevant field)
  • 1+ years’ experience in Risk Adjustment and HEDIS/Stars
  • Certified Risk Adjustment Coder or Certified Professional Coder with the American Academy of Professional Coders 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
  • Knowledge of ICD10-CM coding
  • Advanced proficiency in MS Office (Excel, PowerPoint and Word)
  • Must be able to work effectively with common office software, coding software, EMR and abstracting systems.

Preferred Qualifications:  

  • Demonstrate a level of knowledge and understanding of ICD10-CM and CPT coding principles consistent with certification by the American Academy of Professional Coders.
  • Knowledge of EMR for recording patient visits
  • Previous experience in management position in a provider primary care practice
  • 1+ year of coding performed at a health care facility.
  • Knowledge of billing/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

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: ICD-9, ICD-10, CPC, Coder, Trainer, Healthcare, Managed Care, Provider, Medicare, Medicare Risk Adjustment, KY, Kentucky, Telecommute, Telecommuter, Telecommuting

Job Details

  • Contest Number777610
  • Job TitleMedicare Consultant – MCAIP - KY
  • Job FamilyNetwork Management
  • Business SegmentOptumInsight

Job Location Information

  • Lexington, KY
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelYes, 75 % of the Time
  • Telecommuter PositionYes
  • Overtime StatusExempt


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Medicare Consultant – MCAIP - KY

UnitedHealth Group
Lexington, KY

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