About Humana


Job Category:

Member Quality & Financials - Medical Coding


United States

Postal Code:


Approximate Salary:

Not Specified

Position Type:

Full time

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Nurse Auditor - Provider Payment Integrity

Humana - Louisville, Kentucky

Posted: 08/3/2018


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.

Humana is seeking an individual to focus on preventing unnecessary payments to providers and recovering overpayments when they happen.
  • Perform routine and special audits of par and no-par provider claims to determine payment accuracy
  • Make recommendations regarding the accuracy of claim payments and process improvements
  • Utilize Excel and Access to launch theoretical claim queries into the system
  • Review and audit claims that match the query
  • Contact providers to discuss overpayments and arrange recovery


Required Qualifications

  • Associate’s or Bachelor’s Degree
  • RN or LPN
  • Medical claims review and chart audit experience
  • Working knowledge of Microsoft Excel and Access
  • 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

Preferred Qualifications

  • Previous coding experience
  • CPC or any other coding relevant coding certification
  • 2 years of previous claims processing experience

Additional Information

Scheduled Weekly Hours


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