RN - Nurse Auditor - HCC Program Management

Presbyterian Healthcare Services; Albuquerque (NM); On-site; USD 67,100 - 102,460; Full time

Benefits offered by this job

Tuition reimbursement

Malpractice liability insurance

Wellness program access

Job summary

A healthcare organization is seeking an RN - Nurse Auditor to perform clinical audits and validate medical documentation for Medicare services in Albuquerque, NM. Candidates should possess a New Mexico nursing license and preferably have experience in medical claims review. This full-time role emphasizes teamwork, analytical skills, and compliance with healthcare regulations. Competitive compensation with benefits including tuition reimbursement and a wellness program is offered.

Qualifications

• Licensure: Valid New Mexico Nursing license (RN).
• Certifications preferred: Certified Medical Audit Specialist, Certified Risk Adjustment Coder, Certified Professional Coder.
• Three years preferred experience in medical claims review.

Responsibilities

• Perform clinical audit processes for Medicare documentation accuracy.
• Validate medical documentation for Medicare Risk Adjustment.
• Identify cases for follow-up care by relevant providers.

Skills

Strong analytical skills

Excellent communication skills

Teamwork ability

Proficiency in Microsoft Office

Education

New Mexico Nursing license (RN)

Associate Degree or graduate of practical nursing program

Tools

EPIC electronic charting system

Job description

RN - Nurse Auditor - HCC Program Management

Location: 9521 San Mateo NE, Albuquerque, New Mexico 87113-2237, United States of America

Compensation: Minimum $67,100.80 – Maximum $102,460.80 (annual)

Job Summary

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 HCC and refers cases for follow‑up care by disease management, case management, and primary care providers. Applies prospective and retrospective medical claims audit criteria, and conducts clinical and financial review of medical records—including inpatient facility bill audits, provider offices and clinics, pharmacy and other specialties—to ensure services billed were rendered and documented, at the appropriate level, and meet quality standards. Identifies root cause analysis of audit findings and submits recommendations for change management.

Benefits

• Educational and career development options, including tuition and certification reimbursement, scholarship opportunities
• Staff safety (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

Employment Details

Opportunity Type: Full time

Full Time Equivalent (FTE): 1

Job Exempt: Yes

Work Shift: Weekday Monday‑Friday (United States of America)

Job Description ID: Nurse Auditor‑RN‑HCC/ICS‑ABQ

Qualifications

• Licensure: New Mexico Nursing license (RN)
• Certifications preferred: Certified Medical Audit Specialist, Certified Risk Adjustment Coder, Certified Professional Coder.
• Associate Degree equivalent or graduate of accredited practical nursing program (college or vocational/technical school).
• Completion of formal course in coding principles (Coding Bootcamp or equivalent) within 6 months of hire.
• Three years preferred experience in medical claims review for accuracy and applicability to all types of health insurance programs, including Medicare and Medicaid.
• Experience with ICD‑10‑CM diagnosis coding.
• Experience preferred in auditing principles and practices for billing audits and claims forms.
• Knowledge of all state and federal regulations concerning use, disclosure, and confidentiality of patient records.
• Strong analytical and organizational skills; ability to conduct detailed research and coordinate tasks.
• Excellent oral and written communication skills; ability to articulate complex issues and action plans.
• Teamwork ability and ability to work cooperatively with other employees and departments.
• Proficiency with Windows and Microsoft Office products.
• Can work with minimal supervision.
• Updated: 1/4/2017

Well‑Being & Inclusion

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. Presbyterian is committed to an inclusive and equitable environment where everyone is valued and empowered for success.

AA/EOE/VET/DISABLED. PHS is a drug‑free and tobacco‑free employer with smoke‑free campuses.

Compensation Disclaimer

The 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.