Senior Fraud and Waste Investigator, Special Investigations Unit (SIU)- Medicaid

Humana • LA

320d • $71,100 - $97,800

About The Position

This Senior Fraud and Waste Investigator will serve as Humana’s Program Integrity Officer, who will oversee the monitoring and enforcement of the fraud, waste, and abuse (FWA) compliance program to prevent and detect potential FWA activities pursuant to state and federal rules and regulations. This position will act as primary point of contact for Louisiana Department of Health (LDH) and other agencies such as the Medicaid Fraud Control Unit (MFCU) and coordinate all aspects of FWA activities in Louisiana to increase Medicaid program transparency and accountability.

Requirements

• Must be a Louisiana resident
• At least 2 years of healthcare fraud investigations and auditing experience
• Knowledge of healthcare payment methodologies
• Strong organizational, interpersonal, and communication skills
• Inquisitive nature with ability to analyze data to metrics
• Computer literate (MS, Word, Excel, Access)
• Strong personal and professional ethics
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Nice To Haves

• Bachelor's or 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

• Carry out the provisions of the compliance plan, including FWA policies and procedures
• Investigate allegations of FWA and implement corrective action plans
• Assess records and independently refer suspected member fraud, provider fraud, and member abuse cases to the Louisiana Department of Health (LDH) and other duly authorized enforcement agencies
• Coordinate across all departments to encourage sensible and culturally-competent business standards
• Oversee internal investigations of FWA compliance issues
• Work with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve LDH FWA contract compliance issues
• Respond to FWA questions, problems, and concerns from enrollees, providers, and LDH Program Integrity
• Cooperate effectively with federal, state, and local investigative agencies on FWA cases to ensure best outcomes; work closely with internal and external auditors, financial investigators, and claims processing areas
• Adequately staff and manage the program integrity investigator(s) responsible for all FWA detection programs and activities
• Assist in developing FWA education to train staff, providers, and subcontractors
• Attend State Agency meetings

Benefits

• Medical, dental and vision benefits
• 401(k) retirement savings plan
• Paid time off, company and personal holidays, volunteer time off
• Paid parental and caregiver leave
• Short-term and long-term disability
• Life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Bachelor's degree