Fraud and Waste Investigator
About The Position
Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations with law enforcement authorities. Assembles evidence and documentation to support successful adjudication, where appropriate. Conducts on-site audits of provider records ensuring appropriateness of billing practices. Prepares investigative and audit reports. Begins to influence department’s strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments.
Requirements
- Bachelor's degree or equivalent work experience
- 2 years of healthcare fraud investigations and auditing experience
- Knowledge of healthcare payment methodologies, claims, submissions, and payments
- Strong organizational, interpersonal, and communication skills
- Inquisitive nature with ability to analyze data to metrics
- Proficiency with MS Word, Excel, Access
- Strong personal and professional ethics
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
- Self-starter and organized
- Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements
- Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance).
- Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform
- Performing Investigative research and medical record reviews
- CPT code experience
Nice To Haves
- Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI)
- Experience testifying in court
- 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.
- Collaborates in investigations 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 investigative and audit reports.
- Influences department’s strategy.
- Makes decisions on issues regarding technical approach for project components.
- Exercises good judgment with considerable latitude in determining objectives and approaches to assignments.
Benefits
- Benefits starting day 1 of employment
- Competitive 401k match
- Generous Paid Time Off accrual
- Tuition Reimbursement
- Parent Leave
- Go365 perks for well-being
- 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
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
