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.
- 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.
Registered Nurse - State of New Mexico or Compact State Nursing License or Graduate Nurse Permit required. BLS certification within 90 days of hire.
Associate Degree in Nursing (BSN completion within 5 years of hire)
Benefits are effective day-one (for .45 FTE and above) and include:
Full medical, dental and vision insurance
Flexible spending accounts (FSAs)
Free wellness programs
Paid time off (PTO)
Retirement plans, including matching employer contributions
Continuing education and career development opportunities
Life insurance and short/long term disability programs
Presbyterian Healthcare Services is 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, it is the state's largest private employer with approximately 11,000 employees.
Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.
We are part of New Mexico's history -and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.
Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.
New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.