Become a part of our caring community and help us put health first
 

The Manager, Fraud and Waste Investigator: Nurse Audit/Review 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 Manager, Nurse Audit/Review 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.

The Manager, Fraud and Waste Investigator: Nurse Audit/Review 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. 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.

Use your skills to make an impact
 

WORK STYLE: Remote, work at home (associates can opt to work in a local Humana office). While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

WORK HOURS:  Typical work hours are Monday-Friday, 8 hours/day, 5 days/week.

Required Qualifications

• 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

Preferred Qualifications

• Master's Degree in Business, Finance or related fields

• Healthcare Insurance Industry knowledge

• CPC preferred

Additional Information

Work at Home Requirements

•            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 equipment appropriate to meet the business requirements for their position/job.

•            Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability. Hire Vue (formerly Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview.  If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided.  Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequen