• Conducting audits to assess compliance with ISO standards. • Development and execution of audit plans. • Assessing client facilities to determine conformity. • Evaluating documentation, processes, and procedures. • Identify non-conformities and areas of improvement. • Maintenance of appropriate records. • Submit expense reports and other critical audit documentation. • Maintain acquired auditor credentials.

Role Description As a Certified Medical Claims Auditor (Clinical Bill Review Analyst), you’ll review claims upfront and take a deeper dive to catch billing discrepancies, unbundled charges, and other errors based on standard billing practices and coding guidelines. You’ll help identify savings opportunities and share timely, actionable insights with internal teams and leadership to support the best outcomes for our clients. This role calls for strong communication, solid problem-solving skills, and a high level of attention to detail and organization. - Review medical bills to identify appropriate billing, coding, and savings opportunities. - Analyze and resolve claim discrepancies that require a deeper level of expertise beyond initial review. - Collaborate with the Negotiation team to resolve more complex claim issues and secure additional savings. - Communicate findings to clients through detailed Bill Review Reports and assist in discussing complex bill-related inquiries. - Evaluate and respond to bill reconsideration requests, including those requiring additional research or analysis. - Handle escalated provider inquiries, resolve disputes, and conduct direct negotiations for billing discrepancies. - Provide guidance and mentor junior analysts in claim review best practices. - Assist in identifying trends in billing issues, proposing system/process improvements, and contributing to policy development. - Support training efforts by educating internal teams and clients on changes to codes, edits, and bill review procedures. - Work cross-functionally with internal teams to identify and implement process efficiencies that improve savings and client satisfaction. - Ensure compliance with HIPAA and other regulatory standards. - Perform other duties as assigned. Qualifications - 3+ years of auditing, claims, review and/or billing experience within a healthcare organization. - CPC and/or CIC certification. - Working knowledge of industry coding, ICD-10, CPT, HCPCS Revenue codes etc. - Excellent communication skills, both verbal and written. - Knowledge of CMS guidelines. Requirements - A plus if you have experience in DRG validation. - Knowledge of Health Insurance, Medicare guidelines and various healthcare programs. - RevCycle Pro, Encoder Pro, and/or SuperCoder software experience. Benefits - Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card. - Spending account options: HSA, FSA, and DCFSA. - 401K with company match and immediate vesting. - Flexible working environment. - Generous Paid Time Off to include vacation, sick leave, and paid holidays. - Employee Assistance Program that includes professional counseling, referrals, and additional services. - Paid maternity and paternity leave. - Pet insurance. - Employee discounts on phone plans, car rentals and computers. - Community giveback opportunities, including paid time off for philanthropic endeavors.

Role Description The Nurse Auditor 2 will perform Readmission or Short Stay clinical audits to ensure that medical record documentation and diagnosis coding for services rendered is complete, compliant, and accurate to support optimal reimbursement. You will report to the Manager, Nurse Audit / Review. As the Nurse Auditor 2, you will: - Validate and interpret medical documentation to ensure capture of all relevant admission types - Identify the root cause analysis of audit findings and submit recommendations for appropriate change management - Apply clinical experience to conduct reviews of provider services and billing Work from home position. Qualifications - Active Registered Nurse (RN) license, in your state of residence - 3 or more years of acute or critical care inpatient bedside nursing experience - 1 or more years of claim review or auditing experience Requirements - To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service must meet the following criteria: - At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. - In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. - Humana reserves the right to require associates to upgrade their internet service if necessary. - Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. - Occasional travel to Humana's offices for training or meetings may be required. Benefits - Medical, dental, and vision benefits - 401(k) retirement savings plan - Time off (including paid time off, company and personal holidays, paid parental and caregiver leave) - Short-term and long-term disability - Life insurance - Many other opportunities

• Review and validate medical stop loss aggregate claim reimbursements by auditing claim data, eligibility, plan provisions, and contract terms • Audit aggregate stop loss submissions (weekly/monthly/quarterly/annual) to confirm accuracy • Confirm appropriate treatment of: Coordination of Benefits (COB), subrogation, third-party recovery offsets, Provider credits/refunds, Rx rebates (if contractually relevant) • Reconcile eligibility/enrollment counts • Review Plan & Contract Interpret - Stop loss policy/certificate, endorsements, and amendments • Communicate with underwriting, TPA’s, brokers/producers to resolve discrepancies