Presbyterian Healthcare Services

Analyst

• Maintain and update enterprise-wide and department coding policies and procedures for PHS
• Monitor compliance to external regulatory agency coding rules and regulations
• Coordinate internal and external enterprise-wide coding audits across PHS
• Summarize and track internal and external audit results
• Coordinate and track enterprise-wide training for coding, audit, physician and clinician personnel
• Track corrective action plans for identified low performers
• Perform medical record and billing reviews of denied and appealed claims
• Compile and analyze enterprise-wide coding scorecard metrics for denials, appeals and coding accuracy
• Research regulatory agency regulations
• Correct patient accounts based on audit findings
• Liaise with Information Services, Finance/Patient Financial Services, hospitals, PMG sites, PHP, Home Health, Albuquerque Ambulance, Compliance and ancillary departments
• Maintain accurate, complete and timely documentation
• Maintain and disseminate current legal and regulatory information, including ICD-9, CPT-4, HCPCS and APC updates
• Research coding, billing and charging compliance issues and implement corrective action plans
• Respond to daily coding and auditing inquiries and perform ad-hoc analysis for PHS management
• Gather and analyze information and recommend solutions for business issues
• Respond to client inquiries by telephone and email
• Maintain working knowledge of PHS coding and auditing IT applications
• Investigate patient care and billing concerns
• Analyze and summarize medical record and account audit data and communicate findings to management
• Document inquiry responses and resolutions in information systems
• Assist with audit research and documentation

CDQA Administrative Analyst

Strategy

• Lead development and periodic refresh of multi-year service line strategic plans
• Own service line planning methodology, including market assessment, competitive positioning, demand forecasting, access and capacity analysis, provider resource planning, financial performance evaluation, and strategic priority development
• Direct evaluations of organic growth opportunities, market expansion initiatives, partnerships and affiliations, joint ventures, acquisitions, and major enterprise investments
• Lead cross-functional diligence efforts across strategy, clinical operations, finance, legal and regulatory affairs, technology, and workforce planning
• Develop decision-ready recommendations outlining strategic options, assumptions, value creation opportunities, risks, sensitivities, dependencies, and implementation requirements
• Establish governance structures with roadmaps, milestones, accountable owners, KPIs, benefits tracking, and escalation processes
• Prepare and deliver presentations for executive leadership and governance forums
• Facilitate alignment among executive leaders, physicians, nursing leadership, operations leaders, finance, and analytics teams
• Lead, coach, and develop Strategy Managers and Analysts
• Allocate resources and ensure analytical quality, consistency, and execution excellence
• Serve as deputy and backup to the Vice President, Strategy
• Represent the Strategy function in leadership forums and on enterprise strategic priorities
• Support enterprise priorities across multiple service lines, including growth, access, capacity, network, market position, new sites, new programs, care models, integration, partnerships, acquisitions, investments, transformation, and strategic initiatives
• Produce strategic plans, market assessments, competitive analyses, executive business cases, investment recommendations, partnership and acquisition evaluations, board and executive committee presentations, implementation roadmaps, KPI and benefits realization dashboards, portfolio reviews, and strategic progress updates

Executive Director, Strategy

Patient Access

• Perform primary registration of patient accounts for self-pay, government and commercial accounts for scheduled and unscheduled visits
• Update patient demographics and verify insurance
• Collect point-of-service liabilities
• Document registration information within the ADT system
• Confirm accurate account information to ensure clean billing
• Apply knowledge of Medicare (CMS) and other compliance regulatory guidelines
• Provide customer service to patients and families during registration
• Provide wayfinding assistance to patients and visitors
• Address and attempt to resolve complaints using de-escalation processes
• Manage conflict and request supervisor assistance when needed
• Educate patients about insurance benefits and liabilities
• Review accounts to ensure financial clearance at time of service

Patient Access Advocate – Emergency Department

• Provide primary registration of patient accounts for self-pay, government and commercial accounts on date of service for scheduled and unscheduled visits
• Update patient demographics and verify insurance
• Collect point-of-service liabilities
• Document registration information within the ADT system
• Confirm accurate account information to ensure clean billing
• Apply knowledge of Medicare (CMS) and other applicable compliance regulatory guidelines
• Provide customer service to patients and families during registration interactions
• Provide wayfinding assistance to patients and visitors
• Provide exceptional patient experiences using CARES, AIDET and EPE tools
• Address and attempt to resolve complaints using key words and de-escalation processes
• Manage conflict and request supervisor assistance when needed
• Implement PROMISE and CARES behaviors
• Educate patients regarding insurance benefits and liabilities
• Review accounts to ensure financial clearance at time of service

Patient Access Advocate

Physician Assistant

• Provide direct patient care to an assigned group of outpatient clinic patients
• Prepare patients for rooming, examinations and visits
• Maintain efficient patient flow
• Assist providers with treatments and procedures
• Prepare and administer medications and immunizations
• Remove sutures/staples and perform dressing changes
• Collect and prepare laboratory specimens
• Provide basic patient education
• Set up aseptic and sterile procedures
• Support clerical functions including scheduling, referrals, authorizations and in-basket support in electronic medical records
• Perform other duties as required

Medical Assistant

Medical Director

• Serve as the senior physician executive for the health plan
• Lead all Medical Directors and UM staff members, including clinicians and other clinical staff reviewers
• Provide clinical leadership across affordability, quality, utilization, access, member outcomes, population health, and provider engagement
• Advise executive leadership on clinical risk, utilization trends, medical cost drivers, medical policy, provider behavior, and quality improvement opportunities
• Represent the health plan in physician, provider, regulatory, and delivery system forums
• Serve as the accountable clinical leader for UM medical necessity decision-making
• Oversee adverse determinations, peer-to-peer review, appeals, reconsiderations, clinical escalation pathways, and physician reviewer consistency
• Ensure UM decisions are evidence-based, timely, fair, well-documented, and aligned with applicable requirements
• Maintain clinical oversight of criteria, medical necessity rationale, denial language, decision consistency, and reviewer performance
• Partner with the Healthcare Value Leader to ensure UM operations support timely and compliant clinical decisions
• Own clinical governance for medical policies, clinical criteria, practice guidelines, and evidence-based care standards
• Provide clinical leadership for coverage policy interpretation, new technology review, and emerging clinical practice changes
• Provide clinical guidance for case management, disease management, transitions of care, high-risk member programs, and population health initiatives
• Participate in complex case escalation, avoidable utilization review, post-acute strategy, and clinical intervention design
• Review medical cost and utilization trends with the Healthcare Value Leader, Finance, Actuarial, Analytics, and Network
• Lead initiatives related to inpatient utilization, ED utilization, post-acute care, specialty variation, site-of-care optimization, pharmacy trends, and avoidable admissions
• Support development of clinical interventions that reduce unnecessary utilization while preserving access and quality
• Serve as the health plan’s senior clinical representative to physicians, provider groups, and delivery system leaders
• Lead physician-to-physician conversations on medical necessity, utilization variation, care standards, documentation, quality improvement, and value-based performance
• Support provider education related to clinical criteria, medical policies, UM expectations, appeals, and evidence-based practice
• Partner with Quality, Behavioral Health, and Risk Adjustment leadership on clinical strategy, quality, risk adjustment, behavioral health integration, equity, accreditation, and regulatory requirements
• Provide clinical support for HEDIS, Stars or equivalent quality programs, care gap closure, chronic disease management, and clinical quality initiatives

Chief Medical Officer – Health Plan

• Provide primary support to the provider by anticipating provider needs
• Prepare patients for visits using established preparation guidelines
• Maintain efficient patient flow
• Assist providers with treatments, procedures and visit closure
• Perform medical assistant procedures within the organization's MA scope under provider supervision and PHS policy
• Collect and prepare laboratory specimens
• Perform basic foot care
• Provide clerical support including scheduling, referrals and prior authorizations
• Manage patient calls, in-basket messages and telephone encounters
• Schedule appointments and identify no-shows for rescheduling
• Manage prior authorizations for durable medical equipment, diagnostics, medications and specialties
• Manage referrals for diagnostic testing and specialists
• Track Advanced Directives, FMLA and other patient forms
• Maintain clean, organized, safe and well-stocked exam and procedure rooms
• Communicate pertinent patient data to providers
• Use equipment and perform patient care procedures safely and competently
• Collaborate with the care team on process improvement goals and clinical quality metrics
• Participate in interdisciplinary teamwork and provide responsive, compassionate care

Medical Assistant I

Social Worker

• Provide assessment and evidence-based care to individuals, families, and groups
• Participate in a comprehensive Behavioral Health team providing consultation and liaison services in emergency departments and inpatient medical units
• Support clinical intake, inpatient psychiatric units, outpatient clinics, Behavioral Health Service Line, and Primary Care Service Lines
• Identify, triage, and manage patients with behavioral health problems within varied settings
• Provide skill training through patient education strategies
• Develop behavioral health change plans for individual patients and protocols for target populations
• Perform counseling and case management, including assessment, diagnosis, care planning, intervention, brief psychotherapy, educational groups, discharge planning, and evaluation
• Demonstrate genuineness, empathy, and positive regard in patient and significant-other interactions
• Complete risk-management documentation and follow-up actions, including responding to complaints and contributing to resolution and adverse-risk reports
• Recommend program cost-control measures to the supervisor
• Participate in internal Continuous Quality Improvement activities, including peer review, audits, Joint Commission survey preparation, and clinical-path implementation
• Select and provide clinical supervision to adjunctive therapists and student interns
• Maintain accurate, complete, and current patient-chart documentation
• Recommend safety and therapeutic-quality measures for unit areas or rooms
• Serve as a professional role model and clinical consultant for staff
• Attend ongoing internal and external professional-development events
• Perform other required functions

Behavioral Health Clinician, LCSW/LPCC

• Perform medical assistant procedures after competency completion, within the organization’s MA scope of work and under provider supervision
• Prepare patients for rooming and exams
• Prepare and administer medications and immunizations
• Remove sutures/staples and perform dressing changes
• Collect and prepare laboratory specimens
• Provide basic patient education
• Set up aseptic and sterile procedures
• Perform office-based procedures and basic foot care
• Assist with additional provider-determined procedures
• Participate in orientation of new-hire medical assistants
• Perform regulatory audits as needed
• Assist with visit closure
• Participate with the care team to meet patient-care and clinic needs
• Perform scribe duties after completing PMG scribe training

Care Coordinator

• Facilitate a team approach, including the Interdisciplinary Care Plan team, to ensure appropriate interventions and cost-effective delivery of quality care and services
• Collaborate with members, caregivers, legal representatives, physicians, care providers and ancillary support services
• Conduct in-depth health risk and comprehensive needs assessments covering psychosocial, physical, medical, behavioral, environmental and financial parameters
• Provide care coordination for members with chronic or complex conditions requiring intensive interventions and oversight
• Implement, coordinate and monitor strategies to improve health and quality-of-life outcomes
• Coordinate care through assessment, care planning, implementation, monitoring and evaluation for cost-effective, quality outcomes

Care Coordinator IV

Call Center Representative

• Provide customer service for patients regarding triage, scheduling appointments, referrals, messaging, and maintaining patient demographics
• Respond to incoming calls using skill-based technology while meeting quality standards and performance measurements
• Conduct outbound calls as required and meet established quality and quantity guidelines
• Develop and maintain positive customer and partner relationships
• Act as a member/patient advocate with practitioners, employer groups, and brokers
• Support process and procedure documentation and functional process improvements
• Identify patterns in call inquiries and grievances and conduct root cause analysis
• Research inquiries and special projects and provide accurate benefit interpretation and timely resolutions
• Participate effectively in individual, team, and process improvement initiatives
• Record calls, mail, email, faxes, and walk-in encounters in appropriate databases for analysis and reporting
• Coordinate meetings with customers or partners for training, contracting, and reporting
• Perform other functions as required

Call Center Representative – Patient Services

• Provide customer service to patients regarding scheduling appointments, referrals, messaging, patient triage, and maintaining patient demographics
• Respond to incoming calls routed through skill-based technology
• Conduct outbound calls as required
• Resolve contacts on the initial encounter while meeting quality standards and performance measurements
• Develop and maintain positive customer and partner relationships
• Act as a member/patient advocate with practitioners, employer groups, and brokers
• Support process improvements by documenting processes and procedures
• Identify patterns in call inquiries and grievances
• Conduct root cause analysis in resubmitted and adjusted claims
• Research inquiries and special projects and communicate accurate benefit interpretations and resolutions
• Record calls, mail, email, faxes, and walk-in encounters in appropriate databases
• Assist with coordinating customer or partner meetings for training, contracting, and reporting
• Participate in internal teams, process improvement teams, and initiatives
• Perform other functions as required

General

• Assist vascular sonographers with patient preparation, positioning, and education
• Observe and actively participate in vascular ultrasound procedures under direct supervision
• Learn the operation, maintenance, and proper care of ultrasound equipment
• Support image acquisition, measurements, and preliminary documentation
• Collaborate with vascular and multidisciplinary care teams
• Follow patient privacy, safety, infection prevention, and hospital policies
• Participate in educational opportunities, case reviews, team discussions, and feedback sessions
• Assist with department operations and perform additional responsibilities as assigned

CDQA Administrative Analyst

Executive Director, Strategy

Patient Access Advocate – Emergency Department

Patient Access Advocate

Medical Assistant

Chief Medical Officer – Health Plan

Medical Assistant I

Behavioral Health Clinician, LCSW/LPCC

Medical Assistant

Care Coordinator IV

Call Center Representative – Patient Services

Call Center Representative – Patient Services

Vascular Sonographer Intern