Registered Nurse - Utilization Management/Coder RN

Registered Nurse - Utilization Management/Coder RN

Bienvivir All-Inclusive Senior Health ("Bienvivir") is a community-based, patient-centered, comprehensive health care delivery system that advocates and promotes quality of life, optimum independence, dignity, and choices in a nurturing environment for frail seniors. Since 1987, Bienvivir has served the frail seniors of El Paso, Texas through the provision of the Program of All-Inclusive Care for the Elderly ("PACE").

PACE is a unique managed care benefit for frail seniors (referred to as participants) age 55 and older who are certified by the state as needing nursing home level care and who reside in a PACE service area. PACE programs coordinate and provide comprehensive medical and support services so that participants can remain independent and stay in their homes for as long as safely possible.

Bienvivir is currently accepting applications for the following position:

REGISTERED NURSE - UTILIZATION MANAGEMENT / CODER

The UM/Coder RN integrates Utilization Management (UM) and medical coding to ensure appropriate healthcare service utilization and accurate clinical documentation analysis. This role supports risk adjustment, compliance, claims authorization, and reimbursement processes while adhering to Medicare, Medicaid, and PACE regulatory guidelines. Responsibilities include managing communication processes with the provider networks and the Interdisciplinary Team, supporting utilization management activities, coordinating care transitions, and enhancing documentation accuracy.

RESPONSIBILITIES:

• UTILIZATION MANAGEMENT & CARE COORDINATION: Conduct retrospective reviews of inpatient admissions under 48 hours and claims submitted inconsistently with the service authorization. Perform concurrent and retrospective reviews of acute, subacute, Long-Term Acute Care (LTAC), and Skilled Nursing Facility (SNF) admissions, as well as specialist referrals. Coordinate and review services delivered by contracted providers, ensuring alignment with Interdisciplinary Team service authorization and care plans. Maintains accurate and comprehensive documentation of all patient-related interactions in the Electronic Medical Records (EMR), as well as in the BV Authorization Log, SNF Log, and Hospital Encounters Log. Serves as the liaison with contracted and non-contracted facilities and provider networks for all utilization management communications or related matters, as needed. Assist in coordinating the Utilization Management (UM) committee, collaborating with the Medical Director, VP of Clinical Operations, Director of Nursing, Assistant Director of Nursing, PACE Center Directors, Vice President of Finance, Discharge Coordinator, Director of Pharmacy, Coordinated Care Team, Quality Improvement Data Analyst, Home Health Director, Quality Improvement Manager, and other required staff. Supports provider appeals for rejected claims, collaborating with the Medical Director to ensure appropriate determinations per policy. Analyze key performance indicators (KPIs) monthly for acute care, post-acute care, emergency room utilization, admissions, readmissions to acute care within 30 days of discharge, and referrals to outpatient specialists. Prepare and present utilization reports for committees such as the UM Committee, Committee with Community Input (CCI), and Quality Improvement Committee.
• MEDICAL CODING & DOCUMENTATION: Assign and enter ICD-10, CPT, and HCPCS codes based on clinical documentation and ensure accurate risk adjustment coding for chronic conditions and comorbidities to support reimbursement. Ensure compliance with Medicare, Medicaid, and PACE program guidelines regarding coding and billing practices. Collaborate with healthcare providers, nurses, and other interdisciplinary team members to clarify documentation and improve coding accuracy. Conduct internal audits, review coding accuracy, and resolve discrepancies. Adhere to and enforce Bienvivir service authorization policies, ensuring that participant care and related claims are reasonable and necessary for diagnosis or treatment and consistent with Primary Care Provider (PCP) coordination decisions. Serve as a liaison between Bienvivir and contracted services involved in coding submission for Care Management, ensuring alignment, accuracy, and timely communication across all parties. Prepare and present utilization/coding reports as needed.
• COMPLIANCE, QUALITY, AND PROCESS IMPROVEMENT: Ensure all UM and coding activities comply with federal, state, and organizational policies. Supports or participates in Quality Improvement initiatives to enhance utilization review and documentation accuracy. Maintain accurate documentation in the Electronic Medical Record (EMR) for medical service tracking. Assist in policy development and process standardization to improve coding and UM efficiencies. Advocate for quality care, improved patient outcomes, and reduced hospital stays through critical thinking and advocacy. Collaborate with IT teams to improve data quality, dashboard design, and utilization reporting.
• OTHER DUTIES AS ASSIGNED: Serve as a backup for UM and Coding operations during staff absences. Perform additional tasks as needed to support organizational goals and compliance standards.

QUALIFICATIONS / REQUIREMENTS:

• A graduate of an accredited nursing program with a license to practice in the state of Texas as a Registered Nurse.
• Three (3) years of clinical nursing experience.
• Two (2) years of experience in medical coding and/or utilization management preferred.
• Familiarity with PACE, elder care settings, or risk-based integrated care models preferred.
• Certification in medical coding (CCS, CPC, CRC) preferred.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Strong attention to detail with expertise in medical coding, risk adjustment, and claims review.
• Ability to analyze utilization trends and drive process improvements.
• Excellent communication and leadership skills to collaborate across teams and lead UM discussions.
• Proficiency in Microsoft Office, EMR systems, and clinical technology tools.
• Ability to work independently and within a team-oriented environment.
• Strong organizational and problem-solving skills with efficient task prioritization.
• Bilingual (English/Spanish) preferred.