Job Description

Location: Petaluma, CA

Employment Status: Full-Time, Hybrid

Salary Range: $96,408- $116,766 DOE

GENERAL SUMMARY:
Under the direction of the UM Medical Director and the UM Manager, this position is responsible for
analyzing clinical information submitted by medical providers by evaluating the medical necessity, appropriateness and efficiency of the medical services, procedures and facilities use for commercial and Medicare members. Evaluations are completed using evidence-based guidelines created for non-physician clinicians establishing medical necessity. These duties may include assignments to all venues requiring utilization management such as pre-authorization for inpatient and outpatient services, concurrent inpatient and observation hospital stays, Skilled Nursing Facility (SNF) stays, ambulatory services and other services as required. This job may coordinate utilization management and case management activities. The Utilization Management nurse is knowledgeable about the CA Nurse Practice Act, NCQA, MCG (Milliman Care Guidelines), the Center for Medicare and Medicaid, DMHC and timeliness rules and pertinent state and federal regulations.

-The UM Nurse is the primary contact for all lower-level facilities for both the Bay Area and Central Valley regions.  The Nurse receives referrals from the hospitals and accepts the member to transfer for SNF, Acute Rehab, or Long-Term Acute Care.  Reviews records against MCG guidelines or Medicare guidelines to provide approval or takes the case to the Medical Director if a determined member does not meet criteria.  Follows members while they are in the lower-level facilities to determine ongoing medical necessity at least every 7 days.  Communicates with the facilities when members will need to discharge, assists with discharge planning, and refers the members to our internal Complex Care Team if they require post discharge assistance.

PRINCIPAL ACCOUNTABILITIES:
• Review routine and urgent requests for service authorization on assigned patients in accordance with NCQA timeliness standards and health plan benefit structure.
• Prepares and presents cases for UM Medical Director review in a concise, objective and organized manner.
• Educates and supports members in accessing care using their HMO and Medicare Advantage benefits as indicated.
• Identifies and refers patients to disease management, wellness programs and community resources whenever relevant.
• Utilizes the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others.
• Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.

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Job Requirements

REQUIREMENTS & QUALIFICATIONS:
• Current California RN License with no restrictions.
• Completion of Diploma or Associate’s Degree in Nursing; Bachelor’s Degree in Nursing preferred.
• Minimum five years of clinical experience; two years of experience in Managed Care Organization, Health Plan Utilization Management, Commercial HMO or Medicare, preferred.
• Ability to understand and facilitate communication among team members, patients, families, physicians and medical office staff.
• Ability to communicate effectively with contracted health plans and meet required turn around times.
• Excellent clinical judgment, critical thinking skills and independent problem resolution.
• Knowledge of managed care principles, HMO and Risk contracting arrangements.
• Ability to organize and prioritize workload.
• Proficient typing skills with competency in working with Microsoft Word, Excel, Outlook, varied EMR platforms. Prior experience with Health Care Management/authorization software preferred.
• Excellent telephonic customer service skills.
• Flexibility to learn and work in various RN assignment within the department.
• Ability to work with and provide sensitivity to a variety of culturally diverse communities.

Job Description

Location: Petaluma, CA

Employment Status: Full-Time, Hybrid

Salary Range: $29.19/hr. – $34.60/hr. DOE

Position Summary:
Clinical Coding Specialists are responsible for reviewing patient medical records for Medicare Advantage enrollees, and other groups/populations as assigned, to identify chronic conditions to be prioritized and addressed by healthcare providers. The review process includes working with multiple electronic health records, completing of pre-appointment reviews, completing post-appointment reviews, and reviewing capture of chronic conditions for physician incentives. They must maintain best practices for accurate data collection and adhere to Meritage policies and procedures.

Primary Responsibilities:
• Complete pre-reviews to inform physicians of any outstanding HCC.
• Complete post-review to ensure all codes on the claim are documented in the chart note.
• Provide feedback to physicians and remove codes when documentation does not support coding via charge entry or delete file process.
• Add additional HCC codes when substantiated in the chart note and not on claim via charge entry or supplemental data process.
• Maintain Continued Education Units (CEU) for credentials in addition to any new coding guidelines as it pertains to HCC/Risk Adjustment.
• Assist in educating physicians and staff regarding coding procedures and policies to ensure compliance.
• Maintain HIPAA compliance at all times.
• Adhere to CMS coding guidelines and OIG regulations at all times.
• Monthly updates and reporting to provider network regarding AWV completeness and recapture rates.
• Maintain excellent customer relationships with physicians, medical office staff, health plan partners and internal departments.
• Complete scheduled and ad-hoc chart reviews for provider network and health plans.
• Track coding trends when completing chart reviews and report back to leadership, provider network and/or health plans.
• Contributes to the team’s effort and success by accomplishing delegated tasks on time and meeting daily and weekly job goals.
• Promotes a team approach by encouraging communication among all members of the Risk Adjustment team.
• Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others. • Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion.
• Performs other duties and projects as assigned that support the Care Management Team and other areas, departments and programs within the Meritage organization.

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Job Requirements

Minimum Qualifications & Requirements:
• High School diploma or equivalent (e.g. General Education Diploma “GED”).
• CPC or CCS certification required. CRC certification preferred.
• Minimum of 1 year of risk adjustment coding; current medical background with chart review experience; 2 years of customer service experience in a healthcare related setting.
• Expertise in RAF/HCC, ICD-10-CM and CPT.
• Working knowledge in HCC coding.
• Working knowledge of medical terminology, anatomy and physiology, disease processes and pharmacology.
• Able to work effectively on an independent basis or as part of a larger work team.
• Demonstrates critical thinking skills, sound judgement and a solid sense of accountability.
• Able to concurrently use different electronic health record systems as needed.
• Detail oriented and able to work as a collaborative and positive team member.
• Strong written, verbal and listening communication skills.
• Demonstrates a professional demeanor and excellent customer services skills.
• Treats others in a respectful, kind and patient manner.
• Self-motivated and able to ask for assistance when needed.
• Flexible and adaptable to change.
• Experience with Accountable Care Organization (ACO) or Direct Contracting Entity (DCE), preferred.