Presbyterian Healthcare Services

Role Description The Clinical Program & Population Health Strategist – Commercial is responsible for advancing population health strategy for Commercial populations. This role aligns with Presbyterian’s integrated delivery system (IDS) model and Health Value strategy, partnering across the health plan, medical group, and care delivery system. The Strategist translates enterprise population health priorities into product-specific strategies, clinical program designs, and a prioritized Clinical Initiative Portfolio. This role influences execution through cross-functional partnerships but does not directly manage program operations or vendor performance. - Commercial Population Health Strategy - Develop population health strategies for Commercial populations aligned with enterprise priorities - Identify high-impact opportunities to improve outcomes across preventive care, chronic disease, and rising-risk populations - Ensure alignment with product-specific goals, market competitiveness, contractual requirements, and employer expectations - Clinical Initiative Portfolio Strategy & Prioritization - Support development and refinement of the Clinical Initiative Portfolio - Partner with product owners and leadership to prioritize initiatives based on impact and ROI - Define success metrics aligned with HEDIS, affordability, and utilization goals - Clinical Program Design & Strategic Guidance - Design evidence-based clinical programs and interventions - Define target populations, program goals, and success measures - Partner with program and operational leaders to support implementation and scaling - Inform digital, virtual, and in-person care model integration - Provider Strategy & Performance Enablement - Translate clinical strategies into provider-facing approaches - Support development of provider tools, workflows, and reporting - Provide input into value-based care models and provider performance strategies - Product & Cross-Functional Alignment - Serve as liaison to Commercial product teams - Ensure alignment between benefit design, clinical programs, and population health outcomes - Collaborate with analytics, network, sales, and operational teams - Analytics & Insights - Partner with analytics teams to define measurement frameworks - Use data to identify trends, gaps, and opportunities - Translate insights into actionable recommendations - Market Competitiveness & Innovation - Incorporate market trends, employer expectations, and competitive benchmarks into strategy - Advance digital health, virtual care, and innovative engagement models - Health Equity - Embed health equity into all strategies and program designs - Identify disparities and recommend targeted interventions Qualifications - Bachelor’s degree required; Master’s degree (MPH, MHA, MBA, or related) preferred - 5–10+ years of experience in population health, healthcare strategy, or clinical program design - Experience with Commercial populations - Strong understanding of HEDIS, cost drivers, and utilization - Experience working in a matrixed organization - Strategic thinking and portfolio prioritization - Clinical program design and innovation - Data-driven decision making - Cross-functional collaboration and influence - Strong communication and executive presence - Market and employer awareness Benefits - Comprehensive benefits package including medical, dental, vision, short-term and long-term disability, group term life insurance, and other optional voluntary benefits - Employee Wellness rewards program designed to enhance health and well-being - Opportunities to earn gift cards and more by participating in wellness activities

• Providing customer service for members and providers in PHP benefit plans • Responding to telephone, written, Pres Online, E-Business, chat and in person inquiries • Retaining plan details and basic medical terminology • Collaborating with other employees

Role Description Build your Career. Make a Difference. Presbyterian is hiring a skilled Call Center Representative to join our team. - This role is a work at home role available for Metro Albuquerque residents only at this time. - Responsible for providing customer service for members and providers in all PHP benefit plans. - Ensure callers receive service excellence when responding to telephone, written, Pres Online, E-Business, chat and in person inquiries. - Some key responsibilities include: - High school diploma plus one to three years office/business experience; call center experience preferred. - Claims processing experience in managed care with possible enrollment experience is preferred. - Demonstrated ability to communicate effectively in person and via telephone with members, employer groups, brokers, physicians, and physician office staff. - Written communication skills as well as business writing and presentation skills are required. - Requires strong organizational skills, ability to create, sort and analyze reports (Excel, Access, etc) and system processes. - A thorough knowledge of reimbursement methodologies i.e. DRG, Relative Value Systems, Per Diem, Fee schedule, Capitation, etc. and some knowledge of risk sharing programs helpful. - Some knowledge of CRM and Facets, as well as any other databases that may be used PHS Enterprise wide. - Demonstrated ability to function effectively as a team member. - Requires ability to retain plan details and basic medical terminology. - Must be able to work cooperatively with other employees and function under pressure. - Demonstrated ability to sustain quality standards. - Must be able to prove ability to type 30 wpm with 90% accuracy. Qualifications - High school/GED diploma - One year office/business experience - Call Center experience preferred. Requirements - All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits. Benefits - Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. - Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinars, preventive screening and more. Company Description Presbyterian exists to improve the health of patients, members, and the communities we serve. We are 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, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses. - Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke-free campuses. We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services

• Ensure patient confidentiality and excellent customer service standards are met and exceeded • Maintains thorough knowledge of workflow processes and daily operations within the Health Information Management department and Horizon Patient Folder • Communicates necessary information to maintain staff in alignment with organizational vision, values and strategies • Liaison to the Manager and Supervisor • Responsible for orienting and training new staff • Responsible for maintaining accurate, complete, and timely record processing throughout the Health Information Department • Maintains and encourages appropriate productivity and quality standards for Medical Records personnel • Maintains and monitors Physician suspension log detailing all known suspension issues related to medical record completion • Recommends appropriate action plans where appropriate • Monitors productivity and quality of work performed within the McKesson Electronic Medical Record in relation to record processing and completion • Ensures compliance with CMS, JCAHO, PHS Policies and Medical Staff CMS/JCAHO standards and regulations • Maintains reports, records and statistics • Models effective performance levels and appropriate behavior in alignment with organizational/departmental expectations • Distributes and prioritizes work equitably to staff members • Demonstrates skills at problem resolution and acts as a resource for staff dealing with problems. • Supports established objectives for customer response on retrieving medical information to internal/external providers • Supports established productivity objectives for all duties within the Health Information Management department

Title: Remote Pro Fee Auditor/Educator locations Remote Workers New Mexico time type Full time job requisition id R-3537 Location Address: Remote Office Santa Fe, NM 87501 Compensation Pay Range: Minimum Offer $54,516.80 Maximum Offer $83,262.40 Now Hiring: Remote Pro Fee Auditor/Educator Summary: Build your Career. Make a Difference. Presbyterian is hiring a skilled Remote Pro Fee Auditor/Educator to join our team. Type of Opportunity: Full time Job Exempt: Yes Job is based: Remote Workers New Mexico Work Shift: Days (United States of America) Responsibilities: Presbyterian is seeking a talented Pro Fee Auditor/Educator With minimal supervision directly supports the following responsibilities of the Coding and documentation quality assurance (CDQA) team: implementation of and compliance to enterprise-wide and department coding policies and procedures for PHS; compliance to all external regulatory agency coding rules and regulations; Demonstrates high-level of proficiency in performing and/or managing on-site internal audits or reviews to assess compliance/quality monitoring performed by PHS/PMG departments while serving as a resource on documentation, coding, billing, and coding compliance questions. Works on special coding compliance related projects, develops and presents educational programs, disseminates information to PHS/PMG departments and develops educational tools used to maintain compliance with regulations. Provides support via auditing and training the enterprise-wide corrective action plans for coding, audit, physician and clinician personnel identified as low performers; perform medical record and billing reviews of denied and appealed claims and takes appropriate action to ensure accurate payment of claims; coordinate review and tracking of appealed claims including the communication process with affected payers; research and interpret all regulatory agency regulations Some key responsibilities include: - Liaison to the Manager, Information Services, Finance/Patient Financial Services, all hospitals, all PMG sites, PHP, Home Health, Albuquerque Ambulance, Compliance and all ancillary departments in addressing functional coding, auditing, compliance and training issues and problems. Interacts with all levels of management.esponsible for maintaining accurate, complete and timely documentation in either electronic or hard copy form - Must be able to adapt to frequently changing work priorities and schedules. Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area. This includes but is not limited to all ICD-9, ICD-10, CPT-4, HCPCS and APC updates and changes - Researches coding, billing and charging compliance issues, recommends and implements corrective action plans that assure compliance with regulatory agencies where appropriate. Identifies risks, develops and follows up on action plans, identifies lost revenue opportunities and any overpayments due to errors in coding and/or documentation, and provides compliance education - Assists in the creation of the CDQA Annual Audit Work-plan by utilizing the OIG work plan, Medicare and Medicaid regulations, RAC and other audit agency focuses, as well as internal and external risk assessments - Regularly exercises independent judgment in determining the reliability of data reviewed; recommends changes in existing practices to gain or maintain compliant behavior. Keeps actively informed on the business climate of the healthcare industry - Responds to inquiries and requests daily regarding coding and auditing issues and problems and ad-hoc analysis for all PHS management Qualifications: - High school diploma/GED required. Must possess at least one of the following license/certifications: RHIT, RHIA, CPC, CCS and a minimum of three (3) years experience in coding and/or auditing required. - Audit experience preferred. Excellent written and verbal communication skills. - Excellent written and verbal communication skills. - Detail and results oriented. Ability to work independently and make independent decisions. Medical terminology, ICD-9, CPT-4 and HCPCS knowledge required. - Must have a proficient knowledge of Medicare, Medicaid, and other third party payer documentation, coding, and billing regulations for service lines(s) assigned. - Must possess excellent organizational and planning skills, including the ability to prioritize multiple tasks and perform them both accurately and simultaneously. - Must possess computer skills, especially with Microsoft Word, PowerPoint, and Excel applications. Must be able to use the internet and other resource applications for research purposes and to provide documentation that supports regulations quoted in audits. - Must possess strong written and verbal communication skills in order to communicate in clear, concise terms to management at all levels, including the ability to articulate complex regulatory information in laymans terms. - Must possess a personal presence of a highly qualified professional that is characterized by a sense of honesty, integrity, and the ability to inspire and motivate others. All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits. Wellness Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more. 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 active steps to improve the health of New Mexicans. About Presbyterian Healthcare Services Presbyterian exists to improve the health of patients, members, and the communities we serve. We are 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, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Title: VP-Payer Strategy Location: United States/ CA, IL, ND, NY, OH, WA, and WY./ Albuquerque Job Description: Location Address: Remote Office Austin, TX 78701 Summary: Presbyterian Healthcare Services (PHS) seeks a strategic, influential executive to serve as Vice President of Payer Strategy for the Presbyterian Delivery System (PDS). This is a high-impact role at the intersection of finance, strategy, and payer relations-responsible for shaping how the organization delivers sustainable growth in an increasingly complex reimbursement landscape. This leader will define and execute a system-wide payor contracting and revenue optimization strategy across a diverse and integrated delivery network. The Vice President will lead negotiations, advance value-based care models, and drive net revenue performance across hospitals, medical group, ambulatory services, and specialty service lines. This is an ideal role for a seasoned healthcare executive who combines deep reimbursement expertise, strong financial acumen, and executive presence-with the ability to influence both internal stakeholders and external payer partners in a rapidly evolving healthcare environment. Work Arrangement - Remote: Open to applicants in the United States, excluding CA, IL, ND, NY, OH, WA, and WY. - Hybrid: For individuals within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday. Job Description: Strategic Payor Leadership - Define and execute a system-wide payer contracting strategy aligned with growth, market positioning, and financial performance goals - Develop and implement a comprehensive managed care strategic and tactical plan with clear performance targets - Identify and advance innovative reimbursement models, including value-based and risk-based arrangements Contracting & Negotiation Excellence - Lead and oversee negotiations of commercial and governmental managed care agreements to secure optimal reimbursement - Serve as authorized signatory for managed care contracts - Continuously evaluate contract performance and lead renegotiation or restructuring efforts as needed Revenue Optimization & Financial Performance - Drive initiatives to enhance net revenue yield through contract optimization, recovery efforts, and performance monitoring - Analyze reimbursement trends and implement targeted interventions to address risk areas and improve outcomes - Contribute to financial forecasting, budgeting, and capital planning processes Operational Oversight & Governance - Establish and oversee performance monitoring frameworks and reporting to track managed care outcomes - Ensure robust internal controls, compliance with regulatory requirements, and alignment with enterprise financial systems - Lead system configuration and optimization of contract management tools and reporting capabilities Organizational Leadership & Collaboration - Lead, mentor, and develop a high-performing managed care and contracting team - Foster cross-functional collaboration across Finance, Revenue Cycle, Operations, Strategy, and Physician Integration - Serve as a trusted advisor to executive leadership, providing insights and recommendations on payor strategy and risk Relationship Management & Market Influence - Build and sustain strong relationships with managed care organizations and key external stakeholders - Represent PHS in payer negotiations, regulatory discussions, and industry forums - Collaborate across the enterprise to strengthen market position and grow accretive service lines Success Measures Within the first 12-24 months, the Vice President will: - Strengthen Contract Performance: Improve reimbursement yield and contract effectiveness across the system - Advance Value-Based Strategy: Expand and optimize value-based agreements with measurable financial and quality outcomes - Enhance Revenue Integrity: Identify and execute net revenue improvement and recovery initiatives - Elevate Payer Relationships: Build strategic, durable relationships with key payor partners - Drive Organizational Alignment: Establish clear accountability, metrics, and governance for managed care performance Additional Job Description: Education - Required: Master's degree in Business, Healthcare Administration, Finance, or related field Knowledge & Work Experience - Experience: Minimum of 15 years of progressive experience in payer strategy, managed care contracting, or healthcare finance - Leadership: Demonstrated success in senior leadership roles within integrated health systems or complex healthcare organizations - Reimbursement Expertise: Deep knowledge of reimbursement methodologies, including fee-for-service, value-based care, risk-sharing, and capitation models - Industry Acumen: Strong understanding of healthcare policy, regulatory environments, and evolving payment models Core Competencies - Strategic Negotiator: Proven ability to lead high-stakes payer negotiations and secure favorable outcomes - Financial Acumen: Advanced analytical and financial modeling capabilities with strong business judgment - Enterprise Leader: Experience operating within complex, matrixed healthcare systems - Influential Communicator: Ability to translate complex financial concepts into actionable insights for executive and clinical leaders - Relationship Builder: Skilled at developing trust-based relationships with internal stakeholders and external partners - Change Agent: Demonstrated success leading transformation and driving results in dynamic, evolving environments - High Emotional Intelligence: Navigates conflict, complexity, and ambiguity with diplomacy and professionalism Benefits 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.

Title: Executive Director-Provider Network Oversight Location: 9521 San Mateo NE Albuquerque, NM 87113-2237 time type Full time job requisition id R-5965 Summary: Presbyterian Healthcare Services (PHS) seeks a highly strategic and analytically driven executive to serve as Executive Director of Provider Network Oversight for Presbyterian Health Plan. This is a critical enterprise leadership role responsible for ensuring the integrity, compliance, and performance of the health plan’s provider network—spanning regulatory oversight, financial accuracy, vendor governance, and provider data excellence. In an environment of increasing regulatory scrutiny and complexity across Medicare, Medicaid, and Commercial products, this leader will play a pivotal role in ensuring the organization meets and exceeds network adequacy, access, and transparency requirements while optimizing provider network performance and member experience. With oversight of $4B+ in provider payments and $100M+ in vendor relationships, this role is uniquely positioned at the intersection of finance, provider strategy, operations, and compliance. The Executive Director will partner broadly across the organization to deliver best-in-class network oversight and enable strategic growth through data-driven insights and strong governance. Work Arrangement: • Remote: Open to applicants in the United States, excluding CA, IL, ND, NY, OH, WA, and WY. • Hybrid: For individuals within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday. Job Description: Network Adequacy & Regulatory Leadership - Define and lead enterprise network adequacy strategy, ensuring compliance with CMS, state Medicaid, Marketplace, and Department of Insurance requirements - Oversee development, validation, and submission of regulatory filings, attestations, and audit responses across all lines of business - Serve as senior liaison with regulators, ensuring transparency and alignment on provider access, directory accuracy, and compliance standards - Ensure adherence to mental health parity and access requirements through partnership with network strategy teams Provider Data Governance & Directory Excellence - Establish enterprise provider data governance strategy to ensure accuracy, completeness, and consistency across systems - Lead provider directory operations, including audits, correction workflows, and regulatory documentation - Ensure compliance with CMS, NAIC, and state requirements for directory accuracy, timeliness, and transparency - Partner with IT to enhance provider data systems, automation, and reporting capabilities Vendor & Network Ecosystem Oversight - Lead enterprise strategy, governance, and performance management for national, regional, and wrap provider networks - Oversee vendor portfolio exceeding $100M annually, including contract performance, SLAs, and regulatory compliance - Establish and monitor KPIs for vendor performance, ensuring timely remediation of deficiencies - Ensure seamless integration of external networks into internal systems, reporting, and member-facing tools Financial Integrity & Contract Conformance - Oversee contract conformance monitoring and financial analysis of $4B+ in provider payments - Partner with Medical Economics and Finance to ensure reimbursement accuracy and identify areas for improvement - Develop reporting and auditing frameworks to ensure compliance with contractual terms and mitigate financial risk Analytics, Reporting & Performance Management - Establish network adequacy dashboards, KPIs, and reporting frameworks to identify access risks and network gaps - Provide executive-level insights and recommendations to leadership and governance committees - Lead performance review processes to drive accountability and continuous improvement Leadership & Cross-Functional Collaboration - Build and lead high-performing teams across provider data, network adequacy, and vendor oversight functions - Foster strong collaboration across Finance, IT, Operations, Compliance, and Provider-facing teams - Support enterprise initiatives related to product design, network expansion, and value-based care Success Measures Within the first 12–24 months, the Executive Director will: - Ensure Regulatory Excellence: Achieve consistent compliance with all network adequacy and provider directory requirements across lines of business - Strengthen Data Integrity: Improve provider data accuracy, completeness, and system integration across the enterprise - Enhance Financial Oversight: Optimize contract conformance processes and identify opportunities to improve provider payment accuracy - Elevate Vendor Performance: Strengthen governance and accountability across external network partners and delegated entities - Advance Network Strategy: Deliver actionable insights that improve access, close network gaps, and support strategic growth Additional Job Description: Education - Required: Bachelor’s degree in Healthcare Administration, Business Administration, Information Systems, Public Health, or related field - Preferred: Master’s degree (MBA, MHA, or related discipline) Knowledge & Work Experience - Minimum of 10+ years of progressive experience in provider network management, provider data operations, regulatory reporting, or health plan compliance - At least 5 years of senior leadership experience overseeing enterprise-level teams and vendor relationships - Deep expertise in: - Network adequacy regulations (CMS, Medicaid, Marketplace) - Provider directory requirements and compliance standards - Healthcare finance and reimbursement - Contract conformance, audit processes, and internal controls - National and wrap network models and delegated arrangements Core Competencies - Regulatory Expert: Deep understanding of federal and state network adequacy and transparency requirements - Financial & Analytical Strength: Ability to oversee large-scale financial operations and translate data into actionable insights - Systems Thinker: Expertise in provider data ecosystems, technology integration, and process optimization - Executive Communicator: Strong presence with the ability to engage regulators, vendors, and senior leadership - Operational Leader: Proven ability to lead complex, cross-functional initiatives in matrixed environments - Relationship Builder: Skilled at managing internal and external partnerships with influence and credibility - Change Leader: Drives continuous improvement in highly regulated, evolving environments Benefits 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 campuse

• Codes more than one of the following: inpatient and/or outpatient hospital records, ED records, Home Health & Hospice records and/or professional fee services for PMG specialty providers for the purpose of reimbursement, research and in compliance with Federal regulation according to diagnosis, operation and procedure using the ICD-9/10 CM and CPT-4 classification system. • Ensures adherence to Hospital and Departmental Policies and Procedures. • Reviews patients' entire current medical record, assigning appropriate codes including CPT, ICD and MS-DRG (as defined by UHDDS guidelines and CMS). • Abstracts data essential to the QI department. • Accesses several systems via the computer to research the medical record when needed to complete the coding in a timely manner. • Takes responsibility for accounts receivable by looking for lost documents to ensure all encounters are coded. • Resolves any and all pre-bill edits, denials, etc for assigned accounts. • Maintains and disseminates up-to-date technical knowledge of legal and regulatory information. • Participates in all departmental in-services and updates to stay current with accepted coding guidelines.

Title: Patient Access Advocaten - Senior Location: Remote – New Mexico (Santa Fe, NM) Employment: Full-time Work Type: Hybrid Schedule: Monday–Friday (Weekday Schedule) Salary: $19.25–$28.62 per hour Job Description: Location Address: Remote Office: Santa Fe, NM 87501 Compensation Pay Range: Summary: Build your Career. Make a Difference. Presbyterian is hiring a skilled Patient Access Advocate-Senior. The Senior Patient Access Advocate provides all services needed to resolve the financial clearance of patient accounts of government and commercial accounts prior to billing. Performs all financial clearance functions, including insurance verification, authorization, collection and documentation of patient demographics, quality assurance of registration data, benefit analysis, financial counseling, and pre and post service collections. Type of Opportunity: Full time Job Exempt: No Job is based: Remote Workers New Mexico Work Shift: Weekday Schedule Monday-Friday (United States of America) Responsibilities: Customer Service and Caring Practices: - Achieve exceptional patient experience for patients and patient families by using CARES, AIDET and EPE tools. - Addresses and attempts to appropriately resolve complaints in the moment by using key words at key times and de-escalation processes. - Ability to manage conflict and appropriately request the help of a supervisor when needed. - Implement PROMISE and CARES behaviors in every encounter. - Educates patients for whom they speak regarding insurance benefits. - Ensures accounts are cleared for billing to alleviate patient concerns over hospital financial matters Encounter Components - Performs the patient registration process. Manage the accurate collection of patient data which includes but is not limited to; - Obtain/confirm and enter demographic and other financial and clinical information necessary for final clearance of scheduled and Urgent/Emergent patient accounts. - Review Urgent/Emergent admission accounts for notification, financial clearance and authorization post discharge. - Obtain missing insurance information which can include policy number, group number, date of birth, and insurance phone number if information is missing from account. - Verify insurance for eligibility and benefits using online electronic verification system or by contacting payer directly. - Review and process work queues related to Patient Access to ensure claims are submitted timely and accurately, per department guidelines. - Quality review of accounts falling within the work queues to ensure the insurance information contains accurate policy ID#s, Group Name and Numbers, Subscriber information, Authorization numbers, as well as correct payer and Coordination of benefits prior to billing. - Obtain retro authorization for accounts in which the authorization was pending or not received prior to discharge - Maintain a strong knowledge of Medicare (CMS) guidelines as it relates to admissions and outpatient services. Ensuring we are in compliance with admissions forms, benefit entitlement verification, and billing requirements - Quality check accounts relative to MSPs and other Compliance regulations. Report out inaccuracies to leadership as appropriate. Qualifications: - High school diploma/GED - Internal Candidates: 5 years experience in healthcare setting with 2 years of Patient Access and/or billing plus strong customer service background. - Previously passed Patient Access Advocate II, III and Specialist Advancement tests. - CHAA, CHAM or other industry equivalent certification preferred - Expert knowledge of insurance and financial processing of accounts; - Expert knowledge of medical terminology and billing codes (DRG, ICD-10, CPT, HCPCS); - Proficient in EPIC ADT system; include scheduling, registration, contract requirements, financial guidelines, coordination of services and billing process. - Proficient in Microsoft Office Products. - Candidates must be at least 18 years of age at the time of hire All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits. Wellness Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more. 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 active steps to improve the health of New Mexicans. About Presbyterian Healthcare Services Presbyterian exists to improve the health of patients, members, and the communities we serve. We are 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, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses. We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services

Role Description Now Hiring: Remote PRN IP Facility PCS/ICD Coder Codes more than one of the following: inpatient and/or outpatient hospital records, ED records, Home Health & Hospice records and/or professional fee services for PMG specialty providers for the purpose of reimbursement, research and in compliance with Federal regulation according to diagnosis, operation and procedure using the ICD-9/10 CM and CPT-4 classification system. Ensures adherence to Hospital and Departmental Policies and Procedures. - Type of Opportunity: PRN - Job Exempt: No - Job is based: Remote Workers New Mexico - Work Shift: Varied Days and Hours (United States of America) Responsibilities - Reviews patients' entire current medical record, assigning appropriate codes including CPT, ICD and MS-DRG (as defined by UHDDS guidelines and CMS) to be used for financial reimbursement, research in accordance with Federal Regulations and Hospital and Departmental policies. - Abstracts data essential to the QI department in determining patient care issues as well as providing information to The Joint Commission. - Accesses several systems via the computer to research the medical record when needed to complete the coding in a timely manner. - Takes responsibility for accounts receivable by looking for lost documents to ensure all encounters are coded, including the generation of appropriate queries, as needed. - Responsible for resolving any and all pre-bill edits, denials, etc for assigned accounts. - Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area. - Participates in all departmental in-services and updates to stay current with the accepted coding guidelines and improve personal knowledge of medicine and treatment. - Communicates issues to the EW Clinical Coding Manager & Supervisor, as appropriate. - Must demonstrate knowledge of coding multiple areas of service and/or specialties. - Maintains at least a 95% accuracy rate. - Maintains average to high productivity based on PHS Productivity Standards. - Maintains continuing education (CE) requirements per PHS policy. Qualifications - High school diploma/GED required. - Must have any one of the following coding certifications at time of hire: HCS-D, CCS, CCS-P, CPC-H or CPC, or RHIT/RHIA with achievement of one of the coding credentials above within one year of hire. - One-three years experience as a coder required. - Must possess computer skills including, but not limited to, Word, Excel, PowerPoint. - Experience with an encoder preferred. - Experience with an Electronic Medical Record preferred. - Must be able to use the internet and other electronic resources for the purpose of research. Benefits - Comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits. - Employee Wellness rewards program designed to provide engaging opportunities to enhance health and activate well-being. Company Description Presbyterian exists to improve the health of patients, members, and the communities we serve. We are 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, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses. - Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.