Registered Nurse - Audit and Compliance Specialist in El Mirage, AZ
Job Description
Location Address:
9521 San Mateo NE, Albuquerque, New Mexico 87113-2237, United States of America
Compensation Pay Range:
Minimum Offer $: 67100.8
Maximum Offer for this position is up to $: 102460.8
Summary:
As a Registered Nurse - Audit and Compliance Specialist, you will play a critical role in ensuring the accuracy and compliance of medical record documentation and diagnosis coding for Medicare Managed Care Product members, ultimately supporting optimal Medicare reimbursement. Your responsibilities will include:
• Performing clinical audits and validation processes.
• Validating medical documentation to ensure accurate coding based on CMS Hierarchical Condition Categories (HCC).
• Identifying high-risk CMS HCC members and facilitating their follow-up care with appropriate healthcare providers.
• Conducting thorough reviews of medical records, including inpatient facility bill audits, provider offices, clinics, and pharmacy services.
• Identifying root causes of audit findings and recommending changes to improve processes.
Benefits of Working Here:
We prioritize your growth, learning, and professional development with numerous opportunities including:
• Tuition and certification reimbursement.
• Scholarship options.
• Differentials for night/weekend shifts and additional certifications.
• Malpractice liability insurance coverage.
• Loan forgiveness opportunities available through the New Mexico Higher Education Department.
• Access to EPIC electronic charting system.
Type of Opportunity: Full time
FTE: 1
Job Exempt: Yes
Work Shift: Weekday Schedule Monday-Friday (United States of America)
Responsibilities:
As an RN Auditor, you will work collaboratively with various healthcare teams to ensure compliance and accurate documentation in our HCC/ICS program.
Qualifications:
• Current NM Nursing license (RN).
• Preferred certifications include Certified Medical Audit Specialist, Certified Risk Adjustment Coder, or Certified Professional Coder.
• Associate Degree or equivalent from an accredited nursing program.
• Completion of a formal course in coding principles required within 6 months of hire.
• Preferred three years of experience in medical claims review, including working with Medicare and Medicaid programs.
• Understanding of ICD-10CM diagnosis coding.
• Familiarity with auditing principles and practices related to billing audits.
• Knowledge of state and federal regulations regarding patient records confidentiality.
• Strong organizational and analytical skills.
• Ability to interpret complex issues and communicate effectively.
• Proficiency in Microsoft Office and Windows.
• Able to work independently.
Join Us in Making a Difference:
At Presbyterian Healthcare Services, we are dedicated to improving the health of patients and communities we serve. As the largest private employer in New Mexico, we offer a collaborative and forward-thinking environment where you can thrive in your nursing career.
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 considers a variety of factors, including experience and internal equity.
9521 San Mateo NE, Albuquerque, New Mexico 87113-2237, United States of America
Compensation Pay Range:
Minimum Offer $: 67100.8
Maximum Offer for this position is up to $: 102460.8
Summary:
As a Registered Nurse - Audit and Compliance Specialist, you will play a critical role in ensuring the accuracy and compliance of medical record documentation and diagnosis coding for Medicare Managed Care Product members, ultimately supporting optimal Medicare reimbursement. Your responsibilities will include:
• Performing clinical audits and validation processes.
• Validating medical documentation to ensure accurate coding based on CMS Hierarchical Condition Categories (HCC).
• Identifying high-risk CMS HCC members and facilitating their follow-up care with appropriate healthcare providers.
• Conducting thorough reviews of medical records, including inpatient facility bill audits, provider offices, clinics, and pharmacy services.
• Identifying root causes of audit findings and recommending changes to improve processes.
Benefits of Working Here:
We prioritize your growth, learning, and professional development with numerous opportunities including:
• Tuition and certification reimbursement.
• Scholarship options.
• Differentials for night/weekend shifts and additional certifications.
• Malpractice liability insurance coverage.
• Loan forgiveness opportunities available through the New Mexico Higher Education Department.
• Access to EPIC electronic charting system.
Type of Opportunity: Full time
FTE: 1
Job Exempt: Yes
Work Shift: Weekday Schedule Monday-Friday (United States of America)
Responsibilities:
As an RN Auditor, you will work collaboratively with various healthcare teams to ensure compliance and accurate documentation in our HCC/ICS program.
Qualifications:
• Current NM Nursing license (RN).
• Preferred certifications include Certified Medical Audit Specialist, Certified Risk Adjustment Coder, or Certified Professional Coder.
• Associate Degree or equivalent from an accredited nursing program.
• Completion of a formal course in coding principles required within 6 months of hire.
• Preferred three years of experience in medical claims review, including working with Medicare and Medicaid programs.
• Understanding of ICD-10CM diagnosis coding.
• Familiarity with auditing principles and practices related to billing audits.
• Knowledge of state and federal regulations regarding patient records confidentiality.
• Strong organizational and analytical skills.
• Ability to interpret complex issues and communicate effectively.
• Proficiency in Microsoft Office and Windows.
• Able to work independently.
Join Us in Making a Difference:
At Presbyterian Healthcare Services, we are dedicated to improving the health of patients and communities we serve. As the largest private employer in New Mexico, we offer a collaborative and forward-thinking environment where you can thrive in your nursing career.
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 considers a variety of factors, including experience and internal equity.
Job Details
Medical Speciality
Public health
Employment Type
Full-time
Required License
RN (Registered Nurse)
Work Setting
HospitalClinicOffice
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About Presbyterian Healthcare Services
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system based in New Mexico. Established in 1908, they are the state's largest private employer with a dedicated team of nearly 14,000 professionals. With a network of nine hospitals, a comprehensive health plan, and a multi-specialty medical group, Presbyterian Healthcare Services is focused on improving the health of patients, members, and communities they serve. Their health plan caters to over 580,000 members statewide, offering Medicare Advantage, Medicaid, and Commercial health plans. Whether you require medical care or insurance coverage, Presbyterian Healthcare Services provides integrated solutions for individuals and families in New Mexico.