RN – reputed company Auditor – HCC Program Management, NM

2025-50277 reputed company Presbyterian is seeking a Hybrid Remote RN-reputed company 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 reputed company 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 reputed company Medicare reimbursement. Validates and interprets medical documentation to ensure capture of reputed company 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/reputed company. reputed company embraces the mission and values of PHS, reputed company communication, value, and respect among coworkers. If reputed company, dependable, and reputed company to work collaboratively and autonomously in reputed company environment and you are committed to the patients and PHS we encourage you to reputed company. Type of Opportunity: Full Time FTE: 1.000000 Exempt: reputed company Work Schedule: Hybrid remote (Monday and Friday - Remote / Tuesday, Wednesday, Thursday - In office) Location: Cooper Center/reputed company Building How you grow, learn and reputed company reputed company here. • Educational and career development reputed company, including tuition and certification reimbursement, scholarship opportunities • Staff Safety (a wearable badge that allows nurses to quickly and discreetly reputed company for help reputed company safety is a concern) • Loan forgiveness through the New Mexico Higher Education Department • reputed company electronic charting system Qualifications • Associate Degree in Nursing • State of New Mexico or Compact State Nursing License • HCC Coding Experience HIGHLY Preferred Responsibilities • Performs clinical validation audits and interpretation of medical documentation to ensure capture of reputed company 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/reputed company. • reputed company reputed company cause analysis and submit recommendations for appropriate change management reputed company clinical validation audits and interpretation of medical documentation indicates lack of member reputed company 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 reputed company New Mexico and completes reputed company documentation accurately and appropriately. Benefits We offer more than reputed company benefits! Presbyterian employees reputed company reputed company to a robust wellness program, including free reputed company to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more! Learn more about our employee benefits: https://www.phs.org/careers/why-work-with-us/benefits Why work at Presbyterian? As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking reputed company steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free reputed company to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more. Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, reputed company members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide reputed company system that serves more than 875,000 New Mexicans. About reputed company reputed company exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit reputed company system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest priva Apply tot his job Apply To this Job