Role Description
Become a part of our caring community and help us put health first. The Nurse Auditor 2 performs clinical audit/validation processes to ensure that medical record documentation and diagnosis coding for services rendered is complete, compliant, and accurate to support optimal reimbursement. The Nurse Auditor 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
• Validates and interprets medical documentation to ensure capture of all relevant coding.
• Identifies members with high risk CMS Hierarchical Condition Categories (HCC) and refers cases for annual follow-up care by disease management, case management, and primary care providers as appropriate for assessment/intervention.
• Identifies the root cause analysis of audit findings and submits recommendations for appropriate change management.
• Applies clinical and coding experience to conduct reviews of provider codes and billing.
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Follows established guidelines/procedures.
WORK STYLE: Remote/Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day, 5 days/week. Associates are expected to start each day between 6AM and 9AM in their home time zone.
Qualifications
• Active Registered Nurse (RN) license in the state they reside.
• Minimum of 2 consecutive years acute inpatient hospital care experience in critical, intensive care setting within the last 5 years (Not pediatrics or neonatal).
• In-depth knowledge and critical understanding of complex medical diagnoses including, but not limited to, Sepsis, Pneumonia, Acidosis, Renal Failure, Encephalopathy, CVA, DKA, MI, etc.
• Advanced knowledge of MS Office (Word, Excel, etc).
• Excellent writing, editing, interpersonal, planning, teamwork, and communications skills.
• Demonstrated ability to exercise solid judgment and discretion in handling and disseminating information.
• Ability to work independently and manage workload.
• Customer-service focused and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence and commitment to profession.
Requirements
• Bachelor’s Degree in relevant field preferred.
• Inpatient coding certification (AHIMA or AAPC – ex: RHIA, RHIT, CCS, CIS, CIC).
• Inpatient coding claim experience.
• Prospective payment methodologies, DRG auditing experience.
• Clinical documentation improvement knowledge (CDE, CDEI certification).
Benefits
• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave).
• Short-term and long-term disability.
• Life insurance and many other opportunities.
Company Description
Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers, and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it.