Location Address:

9521 San Mateo NE , Albuquerque, New Mexico 87113-2237, United States of America

Compensation Pay Range:

Minimum Offer $:

67100.8

Maximum Offer for this position is up to $:

102460.8

Summary:

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 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. Application of prospective and retrospective medical claims audit criteria, and clinical and financial review of medical records including but not limited to inpatient facility bill audits, provider offices and clinics, pharmacy and other specialties to ensure that services billed were rendered and documented, at the appropriate level, and meet quality standards. Identifies the root cause analysis of audit findings and submits recommendations for appropriate change management

Sign on and relocation bonuses available for qualified candidates.

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

Job Exempt:

Yes

Work Shift:

Weekday Schedule Monday-Friday (United States of America)

Job Description:

Nurse Auditor-RN-HCC/ICS-ABQ

Qualifications:

*Licensure requirements: NM Nursing license (RN ). *Certifications preferred: Certified Medical Audit Specialist [or other nationally recognized nurse auditor certification], Certified Risk Adjustment Coder, or Certified Professional Coder. *Associate Degree equivalent or graduate of accredited practical nursing program which may be either college or community vocational/technical school based required. *Evidence of completion of formal course in coding principles, either Coding Bootcamp or equivalent program that includes knowledge of ICD-10 CM, coding systems is required to be completed within 6 months of hire. This is a condition of continued employment. *Three years experience preferred in medical claims review for accuracy and applicability to all types of health insurance programs, including but not limited to Medicare and Medicaid programs, commercial insurance, third party liability insurance case management. *Experience in the principles of coding including the applicability and interpretation of ICD-10CM diagnosis coding. *Experience preferred in generally accepted auditing principles and practices as they may apply to billing audits, and billing claims forms. *Knowledge of all state and federal regulations concerning the use, disclosure, and confidentiality of all patient records. *Organizational and Analytical skills: Experienced analytical skills as applicable to interpret provider contracts and medical records. Extensive experience with detailed research, coordination and organizational skills. *Ability to articulate orally and in writing an understanding of complex issues and detailed action plans, while best representing the organization professionally. *Ability to work cooperatively with other employees and departments. *Experienced with Windows and Microsoft Office products. *Able to work with minimal supervision. UPDATED: 1/4/2017

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.

Presbyterian is committed to an inclusive and equitable environment where everyone is valued and empowered for success. We believe that our environment should reflect the diversity of our community.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system comprised 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 13,000 employees - including more than 1,200 providers and nearly 3,500 nurses.
Our health plan serves more than 640,000 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 Disclaimer

The 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