Nurse Auditor

The Nurse Auditor 2 performs clinical audit/validation processes to ensure that medical record documentation and diagnosis coding for services rendered is complete, compliant and accurate to support optimal reimbursement. The Nurse Auditor 2 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. Identifies members with high risk CMS Hierarchical Condition Categories (HCC) and refers cases for annual follow-up care by disease management, case management, and primary care providers as appropriate for assessment/intervention. Identifies the root cause analysis of audit findings and submits recommendations for appropriate change management.

Applies clinical and coding experience to conduct reviews of provider codes and billing. 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 in their home time zone.

• 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). For example: ICU, CCU, PCU, med-surg/adult units or a minimum of 2 years DRG Inpatient auditing.
  
  NOTE:
  
  Inpatient experience does not refer to any other levels of care such as ER, OR, Pre-op, PACU, L&D, mother-baby, behavioral health, SNF, care manager/discharge manager, LTC, rehab, outpatient or office/clinic visits such as wound care, oncology, radiology, interventional radiology, lab, hospice, or home health.

• 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

• Bachelor’s Degree in relevant field preferred

• Inpatient coding certification (AHIMA or AAPC – ex: RHIA, RHIT, CCS, CIS, CIC)

• Inpatient coding claim experience

• Prospective payment methodologies, DRG auditing experience

• Clinical documentation improvement knowledge (CDE, CDEI certification)

• 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…