• Licensure requirements: NM Nursing license (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.
• 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 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-9CM diagnosis coding, CPT and HCPCS Level II Coding.
• Experience preferred 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.
Knowledge: Requires detailed knowledge of cost-effective coordination of care in terms of what and how work is to be done as well as why it is done, this level includes interpretation of data. Requires detailed knowledge of managed care principles in terms of theories and practices. Also requires detailed knowledge of contracts and the elements pertaining to contract compliance. Knowledge including but not limited to NM Medicaid Managed Care regulations, NM Department of Insurance regulations and Medicare Advantage program regulations.
Abilities: Mental Power: Ability to make decisions that are varied but are usually confined to situations, which are familiar. There are several defined alternative solutions available.
Mental Power: Ability to determine appropriate courses of action in more complex situations that may not be addressed by existing policies, procedures or protocols. Decisions include such matters as changing in staffing levels, order in which work is done, and application of established procedures.
Physical Power: Walks, sits, stands in place, arm/wrist/hand movement, lifts.
Driving; sitting at computer; using lap top.
(Team) Results-Based Competencies (How + What)
The results-based competencies will be consistent with meeting and/or exceeding the goals and objectives of your departmental/organizational plan. These objectives will consist of the following measurement categories.
o Service Quality Indicator: Customer Satisfaction / Service Quality
o Clinical/Technical/Business Quality Indicator: Technical Quality
o Economic Indicator: Productivity, Cycle Time and Reducing Rework/Waste
(Note: Refer to the Team Results established within your area/cost center for the specific
objectives/ targets for your team.)
Primary Job Functions
• 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.
Presbyterian Healthcare Services - 18 months ago