Humana Clinical Review Consultant in Louisville, Kentucky

Role: Clinical Review Consultant Assignment: Humana Government Business Location: Forum 3, Louisville, KY

Assignment Capsule

The Clinical Review Consultant position works as an integral member of the Claims Cost Management team to identify waste and abuse in provider billing for Humana Government Business. The position will assist in the development and implementation of a new clinical audit program. The Clinical Review Consultant will also perform pre and/or post-pay medical review of claims. The Clinical Review Consultant will conduct in-depth audits of billing and coding for physicians and hospital in an effort to ensure payment accuracy, while assisting with other program integrity initiatives and data analysis efforts. The position utilizes CMS guidelines in addition to Tricare policies and procedures in making clinical determinations as to the appropriateness of payment coverage.

KEY ACCOUNTABILITIES 40% 1. Reviews billed services to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in claims payment policies. Utilizes extensive knowledge of medical terminology, ICD-9-CM, HCPCS Level II and CPT coding in conjunction with processing guidelines established thru CMS and Tricare coverage determinations.

30 % 2. Strong working knowledge of medical billing, reimbursement, and health insurance practices. Understanding of health insurance industry trends and best practices. Incorporates leadership and communication skills to work with physicians, other healthcare professionals and Tricare management. Identifies new opportunities as appropriate from both clinical reference and analytical sources.

20 % 3. Analyzes research inquiries from a multitude of sources and applies solid clinical judgment to determine potential impact to Tricare medical policies. Ability to determine if an update to existing policy logic or content is warranted based on changes to industry or reference data. Performs QA of policy reviews, logic revisions, and research requests performed by others to ensure accuracy. In addition to QA, provides feedback to originator as needed.

10 % 4. Performs other duties as assigned by the Claims Cost Management Manger that contribute to departmental goals and objectives.

Role Essentials

  • Our Department of Defense contract requires U.S. Citizenship for this role

  • Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)

  • Bachelor's Degree in Nursing or Health Related Field (may substitute equivalent education or experience)

  • Nursing experience in Critical Care, Emergency Medicine, Medical Surgical, or Pediatrics Practice Nursing

  • Active, unrestricted State Registered Nursing (RN) license in good standing

  • Three years’ TRICARE or Medicare insurance claims experience

  • Coding and auditing itemized bill review experience (line level reviews)

  • Audit experience with professional and institutional claim review

  • Ability to write routine reports, correspondence and training documents

  • Excellent communication and interpersonal skills

  • Proficiency in Microsoft Access, Excel and Word

Role Desirables

  • Utilization Review or Case Management experience

  • Master’s Degree in Nursing or Health Related Field

  • Certified Clinical Coder, Certified Medical Audit Specialist, Certified Case Manager, Certified Professional Healthcare Management, Certified Professional in Healthcare Quality

Title: Clinical Review Consultant

Location: KY-Louisville

Requisition ID: 188883

Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We also provide free language interpreter services. See our full accessibility rights information and language options.