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Health Risk Educator Consultant

Primary Location: Phoenix, AZ
Additional Locations: AZ-Casa Grande, AZ-Phoenix, AZ-Scottsdale, AZ-Tempe, AZ-Tucson

25-50% of travel throughout Arizona is required.
This is a telework role.

Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies,and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.

Position Summary Mission:

Works with internal business partner (specifically the CRMO clinical coding team), to develop relationships with local network and health care management teams to educate, train, and provide face to face support to physician practice groups who serve our commercial exchange membership (both on and off exchanges, individual and small group clients) in support of risk adjustment.

Fundamental Components:
  • Uses clinical skills to assess, plan, monitor, and evaluate healthcare services in the provider office setting – participating in direct patient care and assessment.
  • Responsible for educating providers on how to properly document medical services and interventions received during face to face member encounters, including proper coding and claim submission for services rendered.
  • Works on-site in physician offices to assist with scheduling appointments for health risk assessments and other related medical services in support of our commercial exchange members who may have a gap in care.
  • Serves as a liaison to peers to provide in-depth clinical knowledge and expertise to support the education of providers.
  • Performs audits of medical records to ensure all assigned ICD-9 codes are accurate and supported by written clinical documentation.
  • Identifies barriers utilizing critical thinking skills to identify improvement opportunities, communicate them to the national team, and help facilitate gains in efficiency and appropriate risk score capture.
  • Leads work groups to develop learning strategies to improve health care delivery performance.
  • Serves as the training resource and subject matter expert to regionally aligned network practices.
  • Identifies and recommends opportunities for process improvements at the practice level to improve overall risk adjustment scores and gaps. Identifies opportunities to promote quality.
  • Shares best practices in risk adjustment across all sites/regions.
  • Simultaneously manages multiple, complex projects.

Background Experience:
-2+ years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing is required
-Experience with ICD-9 codes required
-RN with current unrestricted state licensure required
-3+ years clinical experience required
-Experience/understanding of electronic medical records/electronic health records in the office setting required
-2+ years of experience with Medicare and/or Commercial risk adjustment process required
-Nurses that currently hold no coding certification will be required to obtain the CRC (Certified Risk Adjustment Coder) certification within 6 months post hire.
-Nurses that currently hold the CPC (Certified Professional Coder) certification will be required to obtain the CRC (Certified Risk Adjustment Coder) certification within 6 months post hire
CPC (Certified Professional Coder) certification or CRC (Certified Risk Adjustment Coder) certification preferred
Knowledge of quality of care and member safety issues preferred
Knowledge of regulatory/accreditory guidelines preferred

Additional Job Information:
Position will require regional travel to Aetna’s provider offices, clinics, and facilities. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills required, both verbal and written. Ability to multi-task, prioritize and effectively adapt to a fast paced changing environment Position is sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone, and typing on the computer. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Work is performed in a typical office environment with productivity and quality expectations.

Required Skills:
Leadership - Collaborating for Results, Service - Improving Constituent-Focused Processes, Service - Providing Solutions to Constituent Needs

Desired Skills:
General Business - Communicating for Impact, General Business - Demonstrating Business and Industry Acumen, Leadership - Developing and Executing Strategy

Functional Skills:
Clinical / Medical - Clinical claim review & coding, Clinical / Medical - Consultative informatics, Clinical / Medical - Quality management, Communication - Communication Delivery - Public Speaking

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft PowerPoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Potential Telework Position:

Percent of Travel Required:
25 - 50%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Click To Review Our Benefits (PDF)


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