Optum Health Coding Risk Adjustment Jobs in Pennsylvania

Manager Clinical Performance & Quality Coding

LOCATION: The position requires that you be in the office 3x per week. You must be within a commutable distance of one of our eligible offices.

HOURS: General business hours, Monday through Friday (8-5 central)

Hybrid 2: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

Responsible for leading the quality documentation and value capture for all provider visit medical encounters to ensure application of accurate diagnosis codes (ICD-10 codes).

Primary duties include but not limited to:

• Serves as the primary resource and subject matter expert on all CMS Risk Adjustment and quality documentation.

• Develop and deliver clinical focused training on advance coding and documentation while incorporating coder feedback.

• Liaison to the clinical leadership on alignment of goals and workflows to support value capture initiatives and high-quality clinical documentation.

• Develop performance management plan, KPI's and clinical level tracking to meet quarterly goals for coding timeliness, accuracy, and Risk Adjustment.

• Develop and manage clinical quality reviews to ensure peer review and clinical quality chart audit process including targeting chart reviews, auditing percentages, score guidelines feedback mechanism and ensure compliance with remediation procedures.

• Develop operational and clinical workflows for closing HEDIS care opportunities to ensure practices and health plan success.

• Participate in peer review of medical documentation for completed visits notes as well as patient profile information in EMR.

• Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Required Qualifications

• Requires a current, active, valid, and unrestricted nurse practitioner (NP) or physician assistant (PA) license from the state in which you reside.

• Requires a master's in Nursing (or PA equivalent) and at least 3 years of clinical experience in applying appropriate diagnosis in the Medicare HCC Mode; or any combination of education and experience, which would provide an equivalent background.

• Requires experience with CMS Risk Models.

Preferred Qualifications

• You must have previous management/supervisory experience with direct reports.

• HEDIS experience is preferred.

• Experience with clinical data/documentation integrity is preferred (CDEO or CDEI).

• Prefer AAPC Certified Risk Adjustment Coder (CRC) certification.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.