Presbyterian Healthcare Services

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at Presbyterian Healthcare Services

Posted: 10/1/2020
Job Reference #: 16587

Job Description

Requisition ID
Default: Location : City
Location : Name
Rev Hugh Cooper Admin Center
Default: Location : State/Province (Full Name)
New Mexico


Job Description
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: Yes
Work Schedule: Weekday Schedule Monday-Friday


Reviews medical records relative to allegations of fraud and abuse investigations. Application of retrospective medical claims criteria, clinical and financial review of medical records including but not limited to inpatient and provider offices and clinics, durable medical equipment, chiropractic, rehabilitative therapies, to ensure that services billed were rendered and documented, at the appropriate level, and meet quality standards.


*Performs clinical review of medical records for suspected fraud and abuse provider activity and refers potential member alleged fraud cases for case management assessment/intervention.
*Receives, reviews, verifies, and processes requests for chart audits of 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 audits at facilities in New Mexico and Texas either onsite or by desktop procedure and completes all documentation accurately and appropriately, including sign-off signatures from hospital auditors and enters outcome data into Amisys system and pended queues.
*Prepares written reports for finance and claims departments including explanations for recovery of money.
*Educates provider services, claims, recovery, 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 quality, health services, pharmacy, credentialing, provider services, member services, underwriting, finance, claims recovery, legal/compliance departments and committees based on analysis and trending of hospital or provider audits.
*Prepares and maintains audit reports to Health Plan finance department and appropriate regulatory agencies including but not limited to New Mexico Human Services Department, Medicaid Fraud Control Unit, Office of Inspector General, Office of Personnel Management, Insurance Fraud Bureau.
*Advises manager of possible trends in inappropriate utilization (under and/or over) , and other quality of care issues.
Performs other functions as required.


PLEASE NOTE: This Position Requires Experience in the principles of coding including the applicability and interpretation of ICD-9CM diagnosis coding, CPT and HCPCS Level II Coding or must be obtained within one year of employment. CANDIDATES WHO ARE SELECTED FOR THE POSITION MUST SIGN AN AGREEMENT TO OBTAIN THIS CREDENTIAL

* Associate Degree

* Registered Nurse-NM


Benefits are effective day-one (for .45 FTE and above) and include:

  • Competitive salaries
  • Full medical, dental and vision insurance
  • Flexible spending accounts (FSAs)
  • Free wellness programs
  • Paid time off (PTO)
  • Retirement plans, including matching employer contributions
  • Continuing education and career development opportunities
  • Life insurance and short/long term disability programs

About Us
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.

Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.

We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.

Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.

New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

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

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Application Instructions

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