RN - Nurse Auditor - HCC Program Management

Overview

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.

Type of Opportunity: Full Time FTE: Exempt: Yes Work Schedule: Hybrid remote (Monday and Friday - Remote / Tuesday, Wednesday, Thursday - In office) 

Location: Cooper Center/Admin Building

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)
• Loan forgiveness through the New Mexico Higher Education Department 
• EPIC electronic charting system

Qualifications

• Associate Degree in Nursing 
• State of New Mexico or Compact State Nursing License
• HCC Coding Experience HIGHLY Preferred

Responsibilities

• 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.

Benefits

We offer more than the standard benefits

Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more

Learn more about our employee benefits:

Why work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.

Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.

About Presbyterian Healthcare Services

Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a 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 1,600 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.

Maximum Offer for this position is up toUSD $49.26/Hr.
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.

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