RN - Nurse Auditor - HCC Program Management
 Presbyterian Healthcare Services | |
 United States, New Mexico, Albuquerque | |
| 1100 Central Avenue Southeast (Show on map) | |
 Dec 23, 2025 | |
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Location Address: 9521 San Mateo NE , Albuquerque, New Mexico 87113-2237, United States of AmericaCompensation Pay Range: Minimum Offer $: 67100.8Maximum Offer for this position is up to $: 102460.8Summary: 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 managementSign onandrelocation bonusesavailable for qualified candidates. Type of Opportunity: Full timeFTE: 1Job Exempt: YesWork Shift: Weekday Schedule Monday-Friday (United States of America)Job Description: Nurse Auditor-RN-HCC/ICS-ABQQualifications: *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. UPDATED: 1/4/2017 We're all about well-being, starting with yours. | |