Job: Nurse Auditor HCC Integrity Unit-PAC-Full Time

Nurse Auditor HCC Integrity Unit-PAC-Full Time

Requisition Number: 26199

Location: NM - Albuquerque

Type of Opportunity: Regular Full-Time

FLSA Classification: Exempt

Minimum Experience: 5 years

Minimum Education: Technical Training with High School Degree

Shift: Days

* 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.
* Integrates coding principles in performance of medical audit activity and applies principles of objectivity in performance of medical audit activity.
* Provides clinical interpretation and guidance to fellow auditors and internal staff.
* Upon completion of medical record validation audit, compiles detailed findings and relevant supporting documentation for inclusion in Risk Adjustment submittals.
* Prepares written reports for Medicare Reimbursement including supportive documentation.
* Educates provider services, health services, finance and other department staff on the outcomes of the audit results and assists provider services with educational efforts.
* Provides feedback and process improvement recommendations to appropriate health plan operations departments and participates in workgroups/committee meetings and process improvement solutions as required.
* Advises manager of possible trends in inappropriate utilization (under and/or over), and other quality of care issues.
* Responsible for file maintenance including entry into database for tracking and trending audit results.
* Maintains professional license and certifications and attends annual training conferences including but not limited to those conducted by American Association of Medical Audit Specialists and American Academy of Professional Coders to keep abreast of latest trends in the field of expertise.

* Performs other functions as required.

* Licensure requirements: NM Nursing license (RN or LPN).
* Certifications preferred: Eligible for certification within three years of hire to include both as a Certified Medical Audit Specialist [or other nationally recognized nurse auditor certification], and a 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-9 CM, CPT, DRG and HCPCS coding systems required.
* Five years experience required in HMO/MCO or health plan insurance environment required, with expertise performing utilization management functions (i.e., prior authorization, medical claims review to include prospective and retrospective review, office and hospital audits).
* Three years experience required 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.
* Extensive experience in the principles of coding including the applicability and interpretation of ICD-9CM diagnosis coding, CPT and HCPCS Level II Coding.
* Experienced in generally accepted auditing principles and practices as they may apply to billing audits, billing claims forms, including the UB-04 [CMS-1450] and CMS 1500 forms and charging and billing procedures.
* 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.