[Remote] Nurse Audit Manager at Humana

San Antonio, Texas, United States

Apply Now

Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Registered nurse (RN)
5 or more years of clinical RN experience in a hospital setting
3 or more years of experience providing leadership in a professional setting
Comprehensive knowledge of Microsoft Office, Word, Excel and PowerPoint
Ability to work Eastern Standard Time zone hours
Bachelor’s degree in nursing, health admin, business or related field (Preferred)
Healthcare insurance industry knowledge (Preferred)
Experience validating and interpreting medical record documentation (Preferred)
Certified Professional Coder or coding knowledge (Preferred)
Claims knowledge and understanding of claims processing (Preferred)

Responsibilities

Validates and interprets medical documentation to ensure capture of all relevant coding
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
Decisions are typically 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
Spearheads audit and validation processes to ensure medical documentation and coding are precise, compliant, and support optimal reimbursement
Leads initiatives and plays a key role in enhancing both operational efficiency and patient outcomes
Upholding the highest standards of clinical integrity within a supportive, mission-driven organization

Skills

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.

Land your dream remote job 3x faster with AI

Try Jobo Free