Nurse Auditor 2 PPI Lab Remote MST CST EST

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Description

The Nurse Auditor 2 will work on the clinical research and development team with coders, clinicians and genetic counselors to develop, implement and maintain clinical lab audit concepts. The Nurse Auditor 2 will perform clinical audit and validation processes to ensure medical record documentation and coding for services rendered is complete, compliant, and accurate to support optimal reimbursement. Performs data mining to identify fraud, waste, and abuse. The Nurse Auditor 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities


Work with a team of coders, clinicians and genetic counselors to develop, implement and maintain clinical lab audit concepts.
Analyzes large files of claims data in Excel to make recommendations for new audit concepts
Identifies the root cause analysis of audit findings and submits recommendations to leadership for appropriate changes to claim selections.
Use clinical and coding knowledge to research Humana Medical Coverage Policies, CMS coverage guidelines, peer reviewed literature, and professional society's publications for potential new audit opportunities.
Assist in the identification of potential fraud, waste, and abuse in prepay and postpay.


What Humana Offers

Our Fortune 100 Company values associate engagement & your well-being. We also provide excellent professional development & continued education.

How we Value You


Benefits starting day 1 of employment
Competitive 401k match
Generous Paid Time Off accrual
Tuition Reimbursement
Parent Leave
*Go365 perks for well-being


Required Qualifications


Associate's Degree in Nursing or higher
Current US Registered Nurse (RN) license, in the state of residence, without any restrictions
Minimum of 1 year of clinical experience reading and interpreting medical records for coding or medical necessity
Comprehensive understanding of CMS regulations and knowledge of medical coding and billing
Demonstrated ability to lead process/project initiatives
MS Office proficiency
Demonstrated ability to exercise solid judgment and discretion in handling and disseminating information
Ability to work independently and manage work load
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
Must be passionate about contributing to an organization focused on continuously improving consumer experiences


Preferred Qualifications


Certification from AAPC or AHIMA - strongly preferred
Bachelor's Degree in Nursing
Experience auditing Lab or Genetic claims
Experience working in SCIOMine, Pareo
Prospective payment methodologies, medical record auditing experience
Experience with pre-authorizations or appeals
Data analytics experience using Excel
CPT procedural code experience


Additional Information

Remote/Work at Home Requirements


Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information


Scheduled Weekly Hours

40

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ****

Company info

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