Remote RN Nurse Auditor – Clinical Coding & Compliance

Humana Inc; Olympia (WA); Remote; USD 78,000 - 108,000; Full time

Job summary

Humana Inc is seeking a Nurse Auditor 2 to perform clinical audit/validation of documentation and coding to support optimal reimbursement. You will interpret medical records, identify high-risk CMS HCC cases, and refer cases for follow-up care when needed.

You will analyze root causes of audit findings and propose changes, applying clinical and coding expertise to reviews of provider codes and billing.

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 (including end-organ failure), Pneumonia, Acidosis, Renal Failure, Encephalopathy, CVA, DKA, MI, etc.
• Advanced knowledge of MS Office (Word, Excel, etc) and strong writing skills.
• 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 HCC and refer cases for annual follow-up care.
• Identify root causes of audit findings and submit recommendations for change management.
• Apply clinical and coding experience to conduct reviews of provider codes and billing.
• Understand department, segment, and organizational strategy and linkages to related areas.
• Make decisions regarding own work methods, occasionally in ambiguous situations, with minimal direction.

Skills

RN license

ICU experience

Critical diagnoses knowledge

Judgement & discretion

Independent work

Customer service

Education

Bachelor’s degree preferred

Tools

MS Office

Job description

Humana Inc is seeking a Nurse Auditor 2 to perform clinical audit/validation of documentation and coding to support optimal reimbursement. You will interpret medical records, identify high-risk CMS HCC cases, and refer cases for follow-up care when needed.

You will analyze root causes of audit findings and propose changes, applying clinical and coding expertise to reviews of provider codes and billing.