Remote Nurse Auditor - Reimbursement Specialist

Humana Inc; Trenton (NJ); Remote; USD 78,000 - 108,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401(k) retirement

Job summary

Humana Inc. is seeking a Nurse Auditor 2 to perform clinical audit/validation of medical record documentation and coding to ensure completeness and accuracy for optimal reimbursement.

The role requires RN licensure, inpatient auditing experience, and strong MS Office skills, with duties including identifying high-risk HCC cases and recommending improvement actions. Remote/work-from-home option with occasional travel for training or meetings.

Qualifications

• 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 (Not pediatrics or neonatal). For example: ICU, CCU, PCU, med-surg/adult units or a minimum of 2 years DRG Inpatient auditing.
• 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

Responsibilities

• Validate and interpret medical documentation to ensure capture of all relevant coding.
• Identify members with high risk CMS Hierarchical Condition Categories (HCC) and refer cases for annual follow-up care by disease management, case management, and primary care providers as appropriate for assessment/intervention.
• Identify the root cause analysis of audit findings and submit recommendations for appropriate change management.
• Apply clinical and coding experience to conduct reviews of provider codes and billing.
• Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• Make decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.

Skills

RN license

Inpatient care

Medical coding

MS Office

Writing skills

Communication

Independent work

Customer service

Education

Bachelor's Degree

Inpatient coding certification

AHIMA/AAPC credentials

Job description

Humana Inc. is seeking a Nurse Auditor 2 to perform clinical audit/validation of medical record documentation and coding to ensure completeness and accuracy for optimal reimbursement.

The role requires RN licensure, inpatient auditing experience, and strong MS Office skills, with duties including identifying high-risk HCC cases and recommending improvement actions. Remote/work-from-home option with occasional travel for training or meetings.