Job Description

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job Summary This position is responsible for performing accurate and timely medical review of regular business, and national accounts claims suspended for medical necessity, contract interpretation, pricing; and to initiate and/or respond to correspondence from providers or members concerning medical determinations.

REQUIRED JOB QUALIFICATIONS:

Registered Nurse with current, active, unrestricted Registered Nurse (RN) license in the state of New Mexico (or reciprocity). For compact licensee changing permanent residence to state of operations, must obtain active, unrestricted RN licensure in the state of operations within 90 days of hire. 3 years clinical experience. Verbal and written communications skills. Analytical and decision making skills. Customer Service PREFERRED QUALIFICATIONS: 1yr+ experience as a Medical Reviewer. Experience analyzing medical records, case reports and clinical documentation for completeness and accuracy. Knowledge of medical coding (ICD-10, CPT) Experience assessing treatment plans, diagnostic procedures and outcomes for medical necessity and appropriateness. Analyzing documentation for regulatory compliance. Experience communicating with case managers to support appeals. This position is expected to adhere to HCSC's hybrid FLEX policy of 3 days/week in office at Albuquerque HQ. Preference in filling vacancies is given to qualified Indian candidates in accordance with the Indian Preference Act of 1934 (title 25, USC Section 472). Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process! Pay Transparency Statement: At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan. HCSC Employment Statement: We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. Base Pay Range $60,300.00 - $133,400.00 Health Care Service Corporation

Job Tags

Holiday work, Permanent employment, Contract work, Flexible hours, 3 days per week,

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