Fraud and Waste Investigator
About The Position
The Fraud and Waste Professional 2 investigates allegations of fraudulent and abusive practices. The role involves varied work assignments that frequently require interpreting information and independently determining appropriate courses of action. The investigator coordinates investigations with law enforcement authorities, assembles evidence and documentation to support adjudication where appropriate, conducts on-site audits of provider records to assess billing practices, and prepares complex investigative and audit reports. The position requires understanding organizational strategy and operating objectives and how they connect to related areas. The role makes decisions about work methods, sometimes in ambiguous situations, while following established guidelines and procedures with minimal direction. This is a remote, work-at-home position. Occasional travel to Humana offices for training or meetings may be required. Typical hours are Monday through Friday, eight hours per day, in the EST or CST time zones. A dedicated home workspace and compliant high-speed internet connection are required to protect member PHI/HIPAA information.
Requirements
- Bachelor's degree.
- Two 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 high-speed DSL or cable modem connection for a home office; minimum speed of 25 Mbps download and 10 Mbps upload. Satellite and wireless internet service are not allowed for this role.
- A dedicated 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.
Responsibilities
- Investigate allegations of fraudulent and abusive practices.
- Coordinate investigations with law enforcement authorities.
- Assemble evidence and documentation to support successful adjudication, where appropriate.
- Conduct on-site audits of provider records to ensure the appropriateness of billing practices.
- Prepare complex investigative and audit reports.
- Make decisions about work methods, including in occasionally ambiguous situations, while following established guidelines and procedures.
Benefits
- Benefits starting on day one of employment.
- Competitive 401(k) match.
- Generous paid time off accrual.
- Tuition reimbursement.
- Parent leave.
- Go365 well-being perks.
- Medical, dental, and vision benefits.
- 401(k) retirement savings plan.
- Paid time off, including company and personal holidays.
- Paid parental and caregiver leave.
- Short-term and long-term disability benefits.
- Life insurance.
- Bonus incentive plan based on company and/or individual performance.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
