RN - Nurse Auditor - HCC Program Management
- [job_card.full_time]
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
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 : Job Exempt :
Yes
Work Shift :
Weekday Schedule Monday-Friday (United States of America)
Responsibilities :
Nurse Auditor-RN-HCC / ICS-ABQ
Qualifications :
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 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
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