Remote Nurse Auditor: Coding & Clinical Audit Expert

Humana Inc; San Juan (PR); Remote; USD 78,000 - 108,000; Full time

Job summary

Humana Inc. is seeking a Nurse Auditor 2 to perform clinical audit/validation of medical records and coding to ensure completeness and accuracy for optimal reimbursement. The role involves interpreting complex diagnoses and identifying high-risk members for follow-up care where needed.

The position is remote with occasional travel to Humana offices for training or meetings. Strong writing, editing, and independent work abilities are essential to succeed.

Qualifications

• Active RN license in the resident state.
• 2 consecutive years acute inpatient hospital care in ICU/CCU/PCU or 2 years DRG inpatient auditing in the last 5 years.
• In-depth knowledge of complex medical diagnoses (sepsis, pneumonia, renal failure, MI, etc.).
• Advanced MS Office skills; strong writing and editing abilities.
• Ability to work independently with sound judgment and strong communication.

Responsibilities

• Perform clinical audits/validation to ensure complete, compliant documentation and accurate coding.
• Identify high-risk CMS HCC members and refer for follow-up care as needed.
• Analyze audit findings, propose change management actions, and document root-cause analysis.
• Review provider codes and billing using clinical and coding experience.
• Support department strategy and operate with minimal direction when appropriate.

Skills

RN license

MS Office

Writing skills

Independent work

Communication skills

Education

Bachelor’s degree preferred

Tools

MS Office

Job description

Humana Inc. is seeking a Nurse Auditor 2 to perform clinical audit/validation of medical records and coding to ensure completeness and accuracy for optimal reimbursement. The role involves interpreting complex diagnoses and identifying high-risk members for follow-up care where needed.

The position is remote with occasional travel to Humana offices for training or meetings. Strong writing, editing, and independent work abilities are essential to succeed.