[Remote] Manager, Fraud & Waste Investigation (Nurse Audit/Review) at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Registered Nurse (RN), holding an active and unrestricted license
Coding knowledge (CPC preferred, but not required)
Bachelor's Degree
3 or more years of management experience in a large corporate environment with accountability of multiple teams or processes
Excellent collaboration and communication skills
Solid understanding of process / workflow concepts
Strong research, problem-solving and analytical skills
Comprehensive knowledge of Microsoft Office, Word, Excel and PowerPoint
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps (wireless, wired cable or DSL connection suggested; satellite, cellular and microwave only if approved)

Responsibilities

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
Works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals
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
Makes decisions related to resources, approach, and tactical operations for projects and initiatives involving own departmental area
Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department

Skills

Key technologies and capabilities for this role

Registered Nurse (RN)CodingCPCMedical Record AuditDiagnosis CodingHCCRoot Cause AnalysisChange ManagementClinical AuditProvider Billing Review

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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