Remote Nurse Auditor: Clinical Coding & Compliance Expert

Humana Inc; Salem (OR); Remote; USD 78,000 - 108,000; Full time

Job summary

Humana Inc. is seeking a Nurse Auditor 2 to perform clinical audit and validation of medical records to ensure documentation and coding accuracy for optimal reimbursement. You will interpret complex clinical data and determine the appropriate actions with minimal supervision.

Responsibilities include identifying high-risk CMS HCCs, referencing root cause analysis, and applying coding and clinical knowledge to provider code reviews while maintaining HIPAA compliance and professional standards.

Qualifications

• Active RN license in the state they reside.
• Minimum of 2 consecutive years inpatient hospital care experience in critical care settings within last 5 years.
• In-depth knowledge of complex medical diagnoses (e.g., Sepsis, DKA, MI).
• Advanced knowledge of MS Office (Word, Excel).
• Excellent writing, editing, interpersonal, planning, teamwork, and communications skills.
• Ability to exercise sound judgment and discretion.
• Ability to work independently and manage workload.
• Customer-service oriented and professional.

Responsibilities

• Perform clinical audit/validation to ensure complete, compliant and accurate documentation and coding for optimal reimbursement.
• Identify high-risk CMS HCCs and refer cases for follow-up care when appropriate.
• Analyze root causes of audit findings and submit change-management recommendations.
• Apply clinical and coding knowledge to provider code reviews and billing.
• Follow guidelines and procedures with minimal direction.

Skills

RN license

Inpatient experience

Complex diagnoses knowledge

MS Office

Writing & communication

Judgment & discretion

Independent work

Customer service focus

Education

Bachelor’s degree preferred

Inpatient coding certification (AHIMA or AAPC)

Inpatient coding claim experience

Prospective payment methodologies / DRG auditing

CDI knowledge (CDE / CDEI)

Tools

MS Office

Job description

Humana Inc. is seeking a Nurse Auditor 2 to perform clinical audit and validation of medical records to ensure documentation and coding accuracy for optimal reimbursement. You will interpret complex clinical data and determine the appropriate actions with minimal supervision.

Responsibilities include identifying high-risk CMS HCCs, referencing root cause analysis, and applying coding and clinical knowledge to provider code reviews while maintaining HIPAA compliance and professional standards.