RN - Nurse Auditor - HCC Program Management

RN - Nurse Auditor - HCC Program Management at Presbyterian Healthcare Services summary:

The RN Nurse Auditor for HCC Program Management performs clinical audits and validates medical record documentation to ensure accurate coding for Medicare Risk Adjustment reimbursement. The role requires clinical knowledge, coding experience, and certification in Risk Adjustment Coding, focusing on identifying high-risk patients and coordinating follow-up care. This hybrid remote position supports compliance and quality assurance in a healthcare setting to optimize Medicare reimbursement.

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 located in Albuquerque NM. Candidates must be local, in Albuquerque Metro area and must be located within 60 miles of this location : 9521 San Mateo Blvd NE Abq, NM 87113

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

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

• 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.

We offer more than the standard benefits!

Presbyterian employees gain access to a robust wellness program, including free access to our…