Manager, Fraud & Waste Investigation (Nurse Audit / Review)

Manager, Fraud And Waste Investigator : Nurse Audit / Review

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.

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. 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

Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements.