Fraud and Waste Investigator - KY

Humana • Indianapolis, IN

2d • $65,000 - $88,600 • Remote

About The Position

The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. Work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Fraud and Waste Professional coordinates investigation with law enforcement authorities. Assemble evidence and documentation to support successful adjudication. Conduct on-site audits of provider records ensuring appropriateness of billing practices. Prepare complex investigative and audit reports. Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receive guidance where needed. Follow established guidelines/procedures.

Requirements

• At least 3 years of healthcare fraud investigations and/or 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
• Self-provided internet service with at least a download speed of 25 Mbps and an upload speed of 10 Mbps.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Nice To Haves

• Candidates who reside in Kentucky or bordering states are preferred.
• Strong clinical experience to include multiple practice areas
• Bachelors, 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

Responsibilities

• Conducts investigations of allegations of fraudulent and abusive practices.
• Coordinates investigation with law enforcement authorities.
• Assembles evidence and documentation to support successful adjudication.
• Conducts on-site audits of provider records ensuring appropriateness of billing practices.
• Prepares complex investigative and audit reports.
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receive guidance where needed.
• Follows established guidelines/procedures.

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
• bonus incentive plan

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed