Clinical Fraud Investigator RN job at Humana in Louisville

Humana is in need of Clinical Fraud Investigator RN on Tue, 16 Jan 2018 21:24:37 GMT. Registered Nurse with current license. Clinical Fraud Investigator RN....

Clinical Fraud Investigator RN

Location: Louisville, Kentucky

Description: Humana is in need of Clinical Fraud Investigator RN right now, this job will be delegated in Kentucky. For detail informations about this job opportunity kindly read the description below.

Role: Clinical Fraud Investigator RN

Assignment: Risk Adjustment Integrity Unit

Location: Virtual (work at home)

We're looking for associates who are dedicated to service and believe in following the Golden Rule of treating others the way you want to be treated. Humana was founded on this premise, and this value is reflected in our expectations for providing perfect service to our consumers, providers, employers, agents and others we work with. At Humana, Perfect Service® means getting the basics done right, delivering value and quality, and providing everyone with personalized attention and guidance. We want to engage with our members through every step of their journey to lifelong well-being. This includes meaningful direct consumer interaction and developing positive relationships with healthcare providers. Humana associates provide Perfect Service every day to our members, employers, providers, and colleagues. We're looking for people who improve their own well-being by looking out for the best interests of others.

Role Description

The purpose of this position is to work on the medical review component of fraud investigations and provide clinical expertise. Investigator will work closely with other members of the RAIU to develop cases and provide support on active cases to include medical record reviews and other investigational steps as needed.

Responsibilities include but are not limited to:

• Assist with case development by providing clinical expertise when performing medical record reviews
• Identify fraud schemes and trends within the assigned line of business or specialties
• Ability to review medical records adhering to department policies and processes
• Ability to testify on behalf of findings
• Support RAIU on complex cases as needed
• Collaborate with other members of the investigative team

Role Essential:

• Registered Nurse with current license
• Bachelor's degree from four year college/university
• Strong clinical experience to include multiple practice areas
• Minimum 2 years of healthcare fraud investigations and auditing experience
• Knowledge of healthcare payment methodologies
• Strong organizational, interpersonal, and communication skills
• Inquisitive nature with ability to analyze data to metrics
• Computer literate (MS, Word, Excel, Access)
• Strong personal and professional ethics

Role Desirables

• BSN
• Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI).
• Understanding of healthcare industry, claims processing and investigative process development.
• Experience in a corporate environment and understanding of business operations
• Knowledge of Humana systems to include CAS, CCP2, MRM and Mediconnect.

Job Type: Full-time

Required education:

• Bachelor's

Required experience:

• healthcare fraud investigations and auditing: 2 years

Required license or certification:

• RN

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If you were eligible to this job, please email us your resume, with salary requirements and a resume to Humana.

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This job starts available on: Tue, 16 Jan 2018 21:24:37 GMT