Nurse Auditor

Humana; United States; Teletrabalho; USD 78 000 - 108 000; Tempo integral

Resumo da oferta

Humana is seeking a Nurse Auditor 2 to perform clinical audit and validation of medical documentation and coding to ensure accuracy and compliance, supporting optimal reimbursement. Remote role with occasional travel to Humana offices for training or meetings.

Requirements include an active RN license, 2+ years inpatient acute care or DRG auditing experience, strong knowledge of complex diagnoses, and advanced MS Office skills. Excellent writing and communication are essential.

Qualificações

• Active RN license in the state of residence.
• Minimum of 2 consecutive years acute inpatient hospital care experience in critical, intensive care setting within the last 5 years.
• In-depth knowledge of complex medical diagnoses (Sepsis, Pneumonia, Renal Failure, MI, etc).
• Advanced knowledge of MS Office (Word, Excel, etc).
• Excellent writing, editing, interpersonal, planning, teamwork, and communications skills.
• Demonstrated ability to exercise sound judgment and discretion in handling information.
• Ability to work independently and manage workload.
• Customer-service focused and professional.

Responsabilidades

• Perform clinical audit/validation to ensure complete, compliant and accurate medical record documentation and coding.
• Identify high-risk CMS HCC cases and refer for annual follow-up by disease/case management or primary care.
• Conduct root-cause analyses of audit findings and submit change-management recommendations.
• Review provider codes and billing using clinical and coding expertise.
• Understand department and organizational strategy and align work with objectives.
• Make independent decisions on work methods, with guidance as needed.
• Follow established guidelines and procedures.

Conhecimentos

RN license

Critical care experience

Medical coding knowledge

MS Office proficiency

Strong written communication

Independent working style

Customer service orientation

Formação académica

Bachelor’s Degree in a relevant field

Inpatient coding certification (AHIMA or AAPC)

Ferramentas

Microsoft Excel

Descrição da oferta de emprego

Become a part of our caring community

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.

The Nurse Auditor 2 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.

Use your skills to make an impact

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.

Required 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). For example: ICU, CCU, PCU, med-surg/adult units or a minimum of 2 years DRG Inpatient auditing. NOTE: Inpatient experience does not refer to any other levels of care such as ER, OR, Pre-op, PACU,L&D, mother-baby, behavioral health, SNF, care manager/discharge manager, LTC, rehab, outpatient or office/clinic visits such as wound care, oncology, radiology, interventional radiology, lab, hospice, or home health.

• In depth knowledge and critical understanding of complex medical diagnoses including, but not limited to, Sepsis (including end-organ failure), 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

Preferred Qualifications

• 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)

Additional Information

Work at Home Requirements

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel: While this is a remote position, occasional travel to Humana’s offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$78,400 - $107,800 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.