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Manager of HEDIS and Risk Adjustment - Charleston

UnitedHealth Group

Greenville, SC
Job Code:
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Job Details

Manager of HEDIS and Risk Adjustment - Charleston(Job Number:695594)

If you who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)


The Manager of HEDIS and Risk Adjustment will be responsible for working directly with providers in a consultative approach to ensure that they are utilizing highly specific codes.  This will be accomplished through coding education and chart review.


The Manager of HEDIS and Risk Adjustment will demonstrate their experience by correlating coding accuracy with correct HCCs & HEDIS / STARS assignments.  The clinical coder is responsible for conducting audits to improve and increase members annual funding in order to drive better patient care. They will assist providers through education and training to improve RAF score and STARS score accuracy.


In this position, you will comply with Coding and Corporate Compliance standards. You will abide by ethical standards and adhere to official coding guidelines and perform other duties as assigned.  The individual in this role will perform the crucial task of assuring accuracy of codes from the listing of International Classification of Diseases, Tenth Revision; (ICD-10-CM), Medicare HEDIS gap analysis and consulting around gap closure to improve Stars ratings. 


Primary Responsibilities:

·        Target local providers who would benefit from our Medical Risk Adjustment & HEDIS / STARS training

·        Contact physicians, medical groups, IPAs and hospitals, and build positive, consultative relationships

·        Educate providers on how to improve their Risk Adjustment Factor (RAF) scores and Stars ratings, which measure their patients' health status

·        Develop comprehensive, provider-specific plans to increase their RAF / STARS performance

·        Train providers on our Risk Adjustment & STARS methods and tools, and implement coding education to providers as needed regarding coding compliance, documentation guidelines, HCC education and Medicare regulations by proactively providing solutions to meet the needs of the provider

·        Collaborate with doctors, coders, facility staff and a variety of internal and external personnel on a wide scope of Risk Adjustment & HEDIS education efforts

·        Conducts onsite physician chart audits (including research and presentation) and identifies potential suspects through clinical documentation where diagnosis is clinically indicated but not documented

·        Assess and interpret whether the coding assigned by the provider was properly assigned based upon review of the medical documentation and application of the coding guidelines 

·        Identify potential suspects through clinical documentation where diagnosis is clinically indicated but not documented; discuss findings with providers for validation

·        Rely upon independent judgment and decision making while at a provider site, whether conducting an audit or providing training/education, both from historical and / or real time data

·        Able to field any questions or concerns and provide solutions that will mirror management’s guidelines

·        Enhance professional growth and development through in-service meetings, and educational programs. 

·        Work independently and rely on professional discretion and judgment; as well as a professional representation of Client / Optum

·        Utilize management for escalation purposes

·        Maintain strictest confidentiality based on HIPPA privacy policy

·        Available to assist other team members in coding, HCC opportunities, HEDIS / STARS and act as a resource to less experienced staff

·        Responsible for maintaining current knowledge of coding guidelines and relevant federal regulations through the use of current HEDIS / ICD-10 CM knowledge

·        Provide feedback and present solutions regarding trends or patterns noticed in provider coding

·        Reports to/works with the Director of Network Programs

*** This position will cover Charleston ***

Job Clinical Analysis & Consulting
Primary Location US-SC-Greenville
Other Location US-SC-Florence, US-SC-Columbia, US-SC-Charleston
Organization RQNS Ops
Schedule Full-time
Number of Openings 1
Apply on the Company Site

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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