Fraud and Waste Investigator

Humana

1d • Remote

About The Position

Become a part of our caring community The Fraud and Waste Professional 2 is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving Florida's Medicaid Program. The Fraud and Waste Professional 2 coordinates investigation 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 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. Use your skills to make an impact

Requirements

• Bachelor's Degree or equivalent work experience
• Reside in Florida
• A minimum of 2 years’ experience conducting comprehensive health care fraud investigations (Medical Coding or Healthcare (Medical Chart Review/Insurance Billing) or Internal/External Audit or Regulatory/Compliance OR Claims Investigations or Criminal Investigation/White Collar Crime); interacting with state, federal and local law enforcement agencies.
• Medical Claim Audit or Medical claim analysis experience.
• Ability to work independently with minimal supervision and manage a high volume of assignments.

Nice To Haves

• Graduate degree 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

• Conducting comprehensive investigations of reported, alleged or suspected fraud involving Florida's Medicaid Program.
• Coordinates investigation 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 complex investigative and audit reports.
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.

Benefits

• Humana provides medical, dental and 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 and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees