Fraud and Waste Investigator

Humana

2d•$65,000 - $88,600•Remote

About The Position

Humana is seeking an experienced Healthcare Investigator to join its Special Investigations Unit. The Fraud and Waste Investigator conducts investigations into allegations of fraudulent and abusive practices, addressing moderately complex to complex issues that require in-depth evaluation of variable factors. The role collaborates with law enforcement, assembles evidence and documentation to support adjudication, conducts on-site audits of provider records to assess billing practices, and prepares investigative and audit reports. The position also contributes to department strategy and determines technical approaches for project components with considerable latitude and good judgment. The investigator regularly works with local, state, and federal law enforcement; Humana Legal and outside counsel; internal Compliance; market areas; clinical teams; business areas supporting Medicare, Medicaid, and Commercial products; and industry trend groups. This is a work-at-home position, with occasional travel to Humana offices for training or meetings. Typical hours are Monday through Friday, eight hours per day, in the EST/CST time zones.

Requirements

Bachelor's degree.
At least 2 years of healthcare fraud investigations within Medicare.
Strong analytical skills and experience utilizing AI in a professional capacity.
Knowledge of healthcare payment methodologies, claims, submissions, and payments.
Strong organizational, interpersonal, and communication skills.
Inquisitive nature and ability to analyze data to metrics.
Proficiency with MS Word, Excel, and Access.
Strong personal and professional ethics.
Passion for contributing to an organization focused on continuously improving consumer experiences.
Ability to provide a qualifying home internet connection: at least 25 Mbps download and 10 Mbps upload; satellite internet is not allowed for this role.
A dedicated home workspace without ongoing interruptions to protect member PHI/HIPAA information.

Nice To Haves

Graduate degree and/or certifications, such as MBA, J.D., MSN, clinical certifications, CPC, CCS, CFE, or AHFI.
Experience testifying in court.
Understanding of the healthcare industry, claims processing, and investigative process development.
Experience in a corporate environment and understanding of business operations.
Interview skills and ability to conduct thorough investigations while maintaining compliance with Humana and governmental requirements.
Comfort with data analysis tools such as Excel, Access, and Power BI, report writing, and creating and presenting materials via PowerPoint or another platform.
CPT code experience.

Responsibilities

Investigate allegations of fraudulent and abusive practices in healthcare.
Collaborate with law enforcement authorities on investigations.
Assemble evidence and documentation to support successful adjudication where appropriate.
Conduct on-site audits of provider records to assess the appropriateness of billing practices.
Prepare investigative and audit reports.
Conduct interviews and investigative research, including medical record reviews.
Analyze data and work with internal and external partners, including Law Enforcement, Legal, and Compliance.
Contribute to department strategy and determine technical approaches for assigned project components.