Fraud and Waste Investigator

Humana

4d • Remote

About The Position

The Fraud and Waste Professional 2 conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Fraud and Waste Professional 2 coordinates investigation with internal and external entities including compliance, internal business partners, and law enforcement. Assembles evidence and documentation to support successful adjudication, where appropriate. 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 receives guidance where needed. Follows established guidelines/procedures.

Requirements

• Bachelor's degree
• Minimum 2 years of experience in healthcare fraud investigations
• 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
• Ability to travel up to 5%, to attend trainings and meetings, as required

Nice To Haves

• Experience in Medicare fraud investigations
• Bilingual in Spanish
• Additional degrees 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 internal and external entities including compliance, internal business partners, and law enforcement.
• Assembles evidence and documentation to support successful adjudication, where appropriate.
• Prepares complex investigative and audit reports.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Follows established guidelines/procedures.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance
• professional development
• continued education

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level