RN - Nurse Auditor - HCC Program Management
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Overview
Job Description
Location Address:
9521 San Mateo NE Albuquerque, NM 87113-2237Compensation Pay Range:
Minimum Offer $67,100.80 Maximum Offer $102,460.80Summary:
Presbyterian is seeking a Hybrid Remote RN-Nurse Auditor for the HCC Program Management Department. This role will support the Hierarchical Condition Categories (HCC) processes for PMG and AHWA Clinics. This is a remote position that requires clinical knowledge and coding experience. The position will require the candidate to become certified in Risk Adjustment Coding within one year of hire. Performs clinical audit/validation processes to ensure that medical record documentation and diagnosis coding for services rendered to Medicare Managed Care Product members is complete, compliant, and accurate to support optimal Medicare reimbursement. Validates and interprets medical documentation to ensure capture of all relevant coding based on CMS HCC conditions that are applicable to Medicare Risk Adjustment reimbursement initiatives. Identifies members with high-risk CMS HCCs and refers cases for annual follow-up care by disease management, case management, and primary care providers as appropriate for assessment/intervention. Our team embraces the mission and values of PHS, open communication, value, and respect among coworkers. If you are accountable, dependable, and able to work collaboratively and autonomously in a team environment and you are committed to the patients and PHS we encourage you to apply now.How you grow, learn and thrive matters here.• Educational and career development options, including tuition and certification reimbursement, scholarship opportunities• Staff Safety (a wearable badge that allows nurses to quickly and discreetly call for help when safety is a concern)• Differentials for night/weekend shifts, higher education, certifications and various lead roles (for eligible positions)• Malpractice liability insurance• Loan forgiveness through the New Mexico Higher Education Department• EPIC electronic charting system
Type of Opportunity: Full time FTE: 1.00 Job Exempt: Yes Work Shift: Days (United States of America)Responsibilities:
• Type of Opportunity: Full Time • FTE: 1.000000• Exempt: Yes• Work Schedule: Hybrid remote (Monday and Friday- Remote / Tuesday, Wednesday, Thursday- In office)
Location: Cooper Center/Admin Building located in Albuquerque NM. Candidates must be local, in Albuquerque Metro area and must be located within 60 miles of this location : 9521 San Mateo Blvd NE Abq, NM 87113
Performs clinical validation audits and interpretation of medical documentation to ensure capture of all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions that are applicable to Medicare Risk Adjustment reimbursement initiatives.
Identifies members with high risk CMS Hierarchical Condition Categories (HCC) and refers cases for annual follow-up care by disease management, case management, and primary care providers as appropriate for assessment/intervention.
Perform root cause analysis and submit recommendations for appropriate change management when clinical validation audits and interpretation of medical documentation indicates lack of member access and provider involvement to manage chronic risk conditions.
Receives, reviews, verifies, and processes requests for prospective and retrospective audits including but not limited to inpatient hospitalizations, diagnostic testing, outpatient procedures and services, home health care services, durable medical equipment, rehabilitative therapies, and pharmacy reviews from finance and/or claims department.
Conducts on-site or desktop audits at provider locations within New Mexico and completes all documentation accurately and appropriately.
Qualifications:
Associate Degree in Nursing
State of New Mexico or Compact State Nursing License
HCC Coding Experience HIGHLY Preferred
We're all about well-being, starting with yours.Presbyterian employees have access to a fun, engaging and unique wellness program, including free on-site and community-based gyms, nutrition coaching and classes, mindfulness and meditation resources, wellness challenges and more.Learn more about our employee benefits.About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.Compensation DisclaimerThe compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.
We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services
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