Fraud and Waste Investigator

Humana•Carolina, SC

1d•Remote

About The Position

The Fraud and Waste Professional conducts comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving South Carolina’s Medicaid Program. The role examines claims, provider billing patterns, medical records, and related documentation; assesses billing accuracy and compliance; and uses healthcare payment knowledge and data analysis to identify irregularities, trends, and potential risk. It also leverages clinical knowledge across practice areas to evaluate medical necessity and appropriateness of services. The investigator assembles and preserves evidence, maintains accurate case files and audit workpapers, coordinates with law enforcement and other partners, and prepares detailed investigative summaries, audit findings, and formal reports. The position manages investigations and audits with minimal direction, applies established policies and procedures with sound judgment, and supports program integrity, fraud prevention, recovery efforts, and improved consumer experiences. This is a fully remote role for someone residing in South Carolina, with occasional travel to Humana offices for training or meetings. Typical business hours are Monday through Friday, with start times between 6 a.m. and 9 a.m., aligned with Central or Eastern Time. The role is scheduled for 40 hours per week. Home-based employees must have internet service with at least 25 Mbps download and 10 Mbps upload speeds and work from a dedicated space that protects member PHI/HIPAA information.

Requirements

Bachelor’s degree.
Strong clinical experience across multiple practice areas.
At least 2 years of healthcare fraud investigations and auditing experience.
Knowledge of healthcare payment methodologies.
Strong organizational, interpersonal, and communication skills.
Inquisitive nature and ability to analyze data to metrics.
Computer literate, including Microsoft Word, Excel, and Access.
Strong personal and professional ethics.
Passion for contributing to an organization focused on continuously improving consumer experiences.
Must reside in South Carolina.
For home-based work, self-provided internet service must provide at least 25 Mbps download and 10 Mbps upload speeds.
Must work from a dedicated space 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.
Understanding of the healthcare industry, claims processing, and investigative process development.
Experience in a corporate environment and understanding of business operations.

Responsibilities

Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving the Medicaid program.
Review claims, provider billing patterns, medical records, and related documentation to identify potential fraud, waste, or abuse.
Analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings.
Assemble, organize, and preserve evidence and supporting documentation for case resolution and adjudication.
Coordinate investigations with law enforcement, regulatory agencies, and other internal or external partners, as appropriate.
Perform on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance with applicable policies and regulations.
Prepare detailed, complex investigative summaries, audit findings, and formal reports for internal leadership and external stakeholders.
Maintain accurate case files, audit workpapers, and documentation in accordance with departmental and regulatory standards.
Use data analysis and performance metrics to identify trends, outliers, and areas of potential risk.
Leverage clinical knowledge across multiple practice areas to evaluate medical necessity, appropriateness of services, and billing practices.
Interpret and apply established guidelines, policies, and procedures while exercising sound judgment in ambiguous situations.
Manage assigned investigations and audits with minimal direction while meeting deadlines and quality expectations.
Communicate findings clearly and professionally, verbally and in writing, to a variety of audiences.
Partner with cross-functional teams to support fraud prevention, recovery efforts, and program integrity initiatives.
Support organizational goals by helping improve program integrity, protect member and provider trust, and enhance the consumer experience.