MGR-SENIOR CLINICAL NURSE AUDITOR-PHP
Location: Albuquerque, New Mexico
Description: Presbyterian Healthcare Services is currently seeking to employ MGR-SENIOR CLINICAL NURSE AUDITOR-PHP right now, this occupation will be delegated in New Mexico. For complete informations about this occupation opportunity please read the description below. Minimum Skills/Requirements
Licensure and Certification requirements: NM Nursing license (RN or LPN), ce! rtified professional coder (CPC), and a certified medical auditor (CMAS or CPMA) required. Associate Degree equivalent or graduate of accredited practical nursing program which may be either college or community vocational/technical school based required. Must complete accreditation requirements for National Health Care (NHCAA), Anti-Fraud Association Accredited Health Care Fraud Investigator (AHFI) and America’s Health Insurance Plans (AHIP) Health Care Anti-Fraud Associate (HCAFA) within 3 years of hire. Five years management experience in HMO/MCO based Utilization
Primary Job Functions
Conducts audits and supervises clinical and non-clinical auditors in the performance of monthly provider profile selection criteria for all lines of business (commercial, ASO, Medicare, Medicaid, FEHBP). Supervision includes ensuring that the profiles validate that medical record documentation and coding for services rendered to PHP members is complete, compliant and ac! curate to support provider reimbursement and that the services! billed were at the appropriate level, and meet quality standards. Manages clinical medical record reviews relative to suspicious activity allegations for fraud and abuse investigations, including investigations related to identity theft and/or material non-disclosure of applications for coverage.
Must complete accreditation requirements for National Health Care (NHCAA), Anti-Fraud Association Accredited Health Care Fraud Investigator (AHFI) and America’s Health Insurance Plans (AHIP) Health Care Anti-Fraud Associate (HCAFA) within 3 years of hire.
Provides daily operational leadership to assigned team members including coordinating activities and/or assignments, evaluating outcomes through defined measurements and standards, and troubleshooting escalated problems.
Prepares mandatory reports to regulators/law enforcement (profile and case notifications), i.e. New Mexico (NM) Human Services Department’s Program Integrity Unit, NM State Attorney! General’s Medicaid Fraud Control Unit, the NM Insurance Division’s Insurance Fraud Bureau, CMS Medicaid Integrity Contractor (MEDIC), Federal Bureau of Investigation, NM Board of Pharmacy, federal and state Offices of Inspector Generals (OIG), and Federal Employees Health Plan (FEHBP) OPM OIG.
Attends with Director monthly/bi-monthly regulatory meetings, i.e. NM Insurance Division’s Insurance Fraud Bureau’s League for Healthcare Justice and NM Human Services Department’s QAB/MCO Program Integrity.
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.
Ensures that auditors prepare and disseminate to other departments (provider services, claims, recovery, and finance) audit outcomes.
Ensures that provider services is notified of aberrant findings and billing practices requiring formal provider educati! onal.
Serves on the PHP Loss Prevention and Recovery Workgroup! , providing feedback and process improvement recommendations based on analysis and trending of hospital or provider audits.
Serves on the PHP Medical Appeals Panel hearings.
Informs Director of possible trends in inappropriate utilization (under and/or over) , and other quality of care issues.
Participates in the selection, hiring, training and evaluation of staff, enabling the most qualified individuals have the feedback, skills, tools and resources necessary to meet the organizational objectives for the Special Investigative Unit.
Participates in responses to information requests from internal and external auditors, consultants, providers, PHP senior management and/or PHP legal/compliance personnel.
Participates in the development and enforcement of departmental policies and procedures.
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If you were eligible to this occupation, please email us your resume, with salary requirements and a resume to Presbyterian He! althcare Services.
Interested on this occupation, just click on the Apply button, you will be redirected to the official website
This occupation will be started on: Tue, 04 Jun 2013 01:54:32 GMT
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