RN - Nurse Auditor - HCC Program Management
About The Position
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
Requirements
- Associate Degree in Nursing
- State of New Mexico or Compact State Nursing License
Nice To Haves
- 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
- 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
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
