Nurse Auditor

Humana

. Perform clinical audit and validation processes to ensure medical record documentation and diagnosis coding are complete, compliant, and accurate .

Posted 9/29/2026full-timeRemote • United StatesJuniorMid-Level💰 $78,400 - $107,800 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical audit processes, medical documentation validation, and coding accuracy, with a strong focus on compliance and patient care. Possesses advanced knowledge of medical diagnoses and coding methodologies, alongside effective communication and teamwork skills.

Highest-signal resume keywords

Active Registered Nurse (RN) LicenseAcute Inpatient Hospital Care ExperienceInpatient Coding Certification (RHIA, RHIT, CCS, CIS, CIC)Clinical Documentation Improvement KnowledgeKnowledge of DRG Auditing

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AuditMedical Documentation ValidationDiagnosis CodingInpatient Coding Claim ExperienceProspective Payment MethodologiesCritical Understanding of Medical DiagnosesChange-Management RecommendationsRoot Cause AnalysisCoding ExpertiseSound Judgment

Soft Skills

Excellent Writing SkillsInterpersonal SkillsPlanning SkillsTeamworkCommunication Skills

Tools & Technologies

MS Office (Word, Excel)Remote Work Tools

Certifications & Qualifications

Registered Nurse (RN) LicenseInpatient Coding Certification (RHIA, RHIT, CCS, CIS, CIC)CDE/CDEI Certification

Industry Keywords

CMS Hierarchical Condition Categories (HCC)Patient CareHIPAA ComplianceClinical Documentation ImprovementDRG Auditing

About the role

Key responsibilities & impact

Perform clinical audit and validation processes to ensure medical record documentation and diagnosis coding are complete, compliant, and accurate
Validate and interpret medical documentation to capture all relevant coding
Identify members with high-risk CMS Hierarchical Condition Categories (HCC)
Refer cases for annual follow-up care by disease management, case management, and primary care providers as appropriate
Identify root causes of audit findings and submit change-management recommendations
Review provider codes and billing using clinical and coding expertise
Interpret department, segment, and organizational strategy and operating objectives and their linkages to related areas
Make decisions regarding work methods in occasionally ambiguous situations with minimal direction
Follow established guidelines and procedures
Work remotely during typical Monday-Friday business hours, 8 hours per day
Occasionally travel to Humana offices for training or meetings

Requirements

What you’ll need

Active Registered Nurse (RN) license in the state they reside
Minimum of 2 consecutive years acute inpatient hospital care experience in a critical or intensive care setting within the last 5 years, excluding pediatrics and neonatal care
Alternatively, a minimum of 2 years DRG inpatient auditing experience
In-depth knowledge and critical understanding of complex medical diagnoses, including Sepsis, Pneumonia, Acidosis, Renal Failure, Encephalopathy, CVA, DKA, and MI
Advanced knowledge of MS Office, including Word and Excel
Excellent writing, editing, interpersonal, planning, teamwork, and communication skills
Demonstrated ability to exercise sound judgment and discretion in handling and disseminating information
Ability to work independently and manage workload
Customer-service focus, professionalism, flexibility, dependability, desire to learn, commitment to excellence, and commitment to the profession
Bachelor's Degree in a relevant field preferred
Inpatient coding certification such as RHIA, RHIT, CCS, CIS, or CIC preferred
Inpatient coding claim experience preferred
Knowledge of prospective payment methodologies and DRG auditing experience preferred
Clinical documentation improvement knowledge or CDE/CDEI certification preferred
Minimum internet speed of 25 Mbps download and 10 Mbps upload for work-from-home arrangements
Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information

Benefits

Comp & perks

Bonus incentive plan based on company and/or individual performance
Medical, dental and vision benefits
401(k) retirement savings plan
Paid time off
Company and personal holidays
Paid parental and caregiver leave
Short-term and long-term disability
Life insurance
Internet expense payment for associates working from home in California, Illinois, Montana, or South Dakota
Telephone equipment provided for Home or Hybrid Home/Office associates
Remote/work-at-home arrangement
Home office internet service support subject to requirements