Nurse Auditor: Home Health Care Clinical Specialist

Become a part of our caring community and help us put health first

The Nurse Auditor 2 performs clinical audit/validation processes to ensure that medical record documentation and coding for services rendered is complete, compliant, and accurate to support optimal reimbursement. The Nurse Auditor 2’s 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. Applies clinical and coding experience to conduct reviews of provider codes and billing. Makes decisions of clinical appropriateness based on submitted provider information. 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.

Remote, work le this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Typical business hours are Monday-Friday, 8 hours/day, 5 days/week. Associates are expected to start each day between 6AM and 9AM EST, regardless of their home time zone.

• Must have current U.S. RN (Registered Nurse) license, in the state of residence, without any restrictions
• Associate must reside in the continental US
• Minimum of 1 year of clinical experience with the Home Health Care Payment Driven Groupings Model (PDGM) and Pay-per-visit (PPV), including reading and interpreting medical records and claims, as well as experience in dispute resolution and analyzing trends in results
• Certified OASIS specialist-Clinical (COS-C) and/or Home Care specialist- OASIS (HCS-O) certification
• Comprehensive understanding of CMS regulations and knowledge of medical coding and billing
• MS Office proficiency (Word, Excel, Teams, Outlook)
• Demonstrated ability to exercise solid judgment and discretion in handling and disseminating information
• Ability to work independently, make decisions and manage workload
• Customer-service focused and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence and commitment to profession
• Excellent writing, editing, interpersonal, planning, teamwork, and communications skills

• HCS-D (Home Care Specialist
  - Diagnostic) certification for ICD-10 coding
• CPT coding experience or certification
• Applied knowledge of Prospective payment methodologies, auditing experience

• 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

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability. Hire Vue (formerly Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If…