Senior Clinical Auditor Author by Humana

Profile

Description

Author, recently launched by Humana, is a service experience designed to meet the whole-health needs of the people we serve. Created to innovate with the speed and agility of a modern start-up and backed by the insights and scale of Humana, Author is pioneering a customer-centered experience designed to foster trusting relationships with members to help them achieve their best health.

Dedicated to simplifying the healthcare experience and helping people navigate their healthcare journey, Author is leveraging digital technologies to eliminate fragmentation and systematic friction for members and providers.

We are seeking individuals who are passionate about solving tough problems as we forge a new path for the healthcare industry. As a member of the Author team, you will have the opportunity to make a difference in the lives and health of the members we serve.

The Senior Clinical Auditor 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 Senior Nurse Auditor work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Clinical Auditor 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. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Required Qualifications

Bachelor's degree

Strong leadership skills

Extensive auditing/medical record review experience

Managed Care experience

Demonstrated ability to lead process/project initiatives

Strong analytical and problem solving 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

CMS knowledge

Additional Information

#Author

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com