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

Role Description Responsible for performing audit and abstraction of medical records (provider and/or vendor) to identify and submit ICD codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures. - Proven ability to support coding judgment and decisions using industry standard evidence and tools. - Proficient in abstraction and assignment of accurate medical codes for diagnoses as documented by physicians and other qualified healthcare providers in the office and/or facility setting. - Sound knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity. - Identify clinically active vs. historical conditions. - Diagnosis codes must be appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures. - Utilize medical records to ensure support is documented for etiology and manifestations of disease processes. - Adhere to stringent timelines consistent with project deadlines and directives. - Conduct self-process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body. Qualifications - Minimum of 1 year recent and related experience in medical record documentation review, diagnosis coding, and/or auditing. - CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) required. Requirements - AA/AS or equivalent experience preferred. - Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 1-2 years for CPC. - High school diploma or equivalent required. Benefits - Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. - Medical, dental, and vision coverage. - Paid time off. - Retirement savings options. - Wellness programs and other resources, based on eligibility.

Role Description Do you want to make a direct impact in improving the lives of refugee children? ICF is looking for an on call, home based Bilingual Child Welfare Professional to travel to facilities that care for unaccompanied refugee children to complete audits on the prevention of sexual abuse of children in care. The auditor will provide a wide range of services based on recognized experience and expertise in auditing and monitoring congregate care facilities such as shelters, group homes, or residential treatment facilities. The Child Welfare professional will work directly to audit, report, develop corrective action plans, and provide follow up in the areas of sexual abuse and sexual harassment prevention. Desired areas of expertise include: - Monitoring - Auditing - Licensing - Investigations in preventing and responding to sexual abuse and harassment Key Responsibilities - Provide expertise in desired areas listed above in consulting with agency or organizational staff on best practice - Provide expertise in the development of tools, reports, and protocols - Travel to assigned sites to complete audits - Review policies, training, reports, and evidence for sites - Write audit reports and corrective action plans - Provide consultation and recommendation for practice improvement - Contribute to regular project reporting and support for activities related to the project’s evaluation, including data collection and continuous quality improvement efforts Qualifications - Bachelor’s degree OR Master's in social work, public administration, or relevant field - Bilingual in English and Spanish - Successfully complete Federal and State criminal background checks (fingerprints) and Child Protective Services (CPS) clearances from each state in which he/she has lived for the past five years due to Government contract Requirements - At least 2 years experience in completing accreditation or licensing audits - At least 2 years experience in child abuse investigations Professional Skills - Excellent interpersonal skills and the ability to build and maintain positive, productive relationships with peers, colleagues, consultants, and professional staff - Exceptional project management skills with a focus on technical assistance project management - Strong analytical, problem-solving, and decision-making capabilities - Ability to multitask and maintain high-quality results in a fast-paced environment - Excellent verbal, interpersonal, and written communication skills - Proficient with MS Office applications (Word, Excel, and PowerPoint) - Ability to gather, organize, and synthesize information for application in technical assistance delivery - 5+ years professional child welfare work experience with at least 3 years of relevant monitoring, evaluation and child welfare experience Time Commitment Each facility audit involves two days onsite work plus travel to/from the site. A minimum commitment of 3 audits per year is requested. Travel Travel is required throughout the US to facilities being audited. Pay Range The pay range for this position based on full-time employment is: $74,090.00 - $125,954.00 Nationwide Remote Office (US99)