Nurse Auditor

🔥 5 minutes ago

🇺🇸 United States – Remote

💵 $78.4k - $107.8k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔎 Auditor

🚫👨‍🎓 No degree required

🦅 H1B Visa Sponsor

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Perform clinical audit and validation processes to ensure medical record documentation and diagnosis coding are complete, compliant, and accurate • Validate and interpret medical documentation to capture all relevant coding • Identify members with high-risk CMS Hierarchical Condition Categories (HCC) • Refer cases for annual follow-up care by disease management, case management, and primary care providers as appropriate • Identify root causes of audit findings and submit change-management recommendations • Review provider codes and billing using clinical and coding expertise • Interpret department, segment, and organizational strategy and operating objectives and their linkages to related areas • Make decisions regarding work methods in occasionally ambiguous situations with minimal direction • Follow established guidelines and procedures • Work remotely during typical Monday-Friday business hours, 8 hours per day • Occasionally travel to Humana offices for training or meetings

🎯 Requirements

• Active Registered Nurse (RN) license in the state they reside • Minimum of 2 consecutive years acute inpatient hospital care experience in a critical or intensive care setting within the last 5 years, excluding pediatrics and neonatal care • Alternatively, a minimum of 2 years DRG inpatient auditing experience • In-depth knowledge and critical understanding of complex medical diagnoses, including Sepsis, Pneumonia, Acidosis, Renal Failure, Encephalopathy, CVA, DKA, and MI • Advanced knowledge of MS Office, including Word and Excel • Excellent writing, editing, interpersonal, planning, teamwork, and communication skills • Demonstrated ability to exercise sound judgment and discretion in handling and disseminating information • Ability to work independently and manage workload • Customer-service focus, professionalism, flexibility, dependability, desire to learn, commitment to excellence, and commitment to the profession • Bachelor's Degree in a relevant field preferred • Inpatient coding certification such as RHIA, RHIT, CCS, CIS, or CIC preferred • Inpatient coding claim experience preferred • Knowledge of prospective payment methodologies and DRG auditing experience preferred • Clinical documentation improvement knowledge or CDE/CDEI certification preferred • Minimum internet speed of 25 Mbps download and 10 Mbps upload for work-from-home arrangements • Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Internet expense payment for associates working from home in California, Illinois, Montana, or South Dakota • Telephone equipment provided for Home or Hybrid Home/Office associates • Remote/work-at-home arrangement • Home office internet service support subject to requirements