Senior Fraud and Waste Investigator

Humana

6d • $71,100 - $97,800 • Remote

About The Position

The Senior Fraud and Waste Investigator conducts investigations of allegations of fraudulent and abusive practices. Work assigned to the Senior Fraud and Waste Investigator involves moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Senior Fraud and Waste Investigator conducts comprehensive investigations into allegations of fraud, misconduct, and other unethical or unlawful activity impacting the organization and its stakeholders. This role focuses on complex, non-traditional investigations, including agent misconduct, internal matters, and other high-risk issues affecting brand integrity and compliance. The Senior Investigator manages end-to-end investigations by gathering and analyzing information, conducting interviews, and synthesizing findings into clear, well-supported conclusions. All investigative activities are thoroughly documented in alignment with organizational and regulatory standards. This role identifies patterns and emerging risks, providing insights to support mitigation strategies and business decisions. The investigator collaborates with internal partners such as Legal, Human Resources, and Compliance, and may coordinate with external regulatory or law enforcement agencies as needed. The Senior Investigator exercises independent judgment in handling complex assignments, influencing investigative strategy, and recommending actions, while working with minimal direction and demonstrating leadership capability.

Requirements

• Bachelor's degree
• At least 3 years of health insurance fraud investigations and other investigative/auditing experience
• Knowledge of healthcare payment methodologies
• Inquisitive nature with ability to analyze data to metrics
• High level of computer literacy (MS, Word, Excel, Access)
• Exceptional organizational, interpersonal, and communication skills
• Strong personal and professional ethics
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

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

• Conducts investigations of allegations of fraudulent and abusive practices.
• Conducts comprehensive investigations into allegations of fraud, misconduct, and other unethical or unlawful activity impacting the organization and its stakeholders.
• Focuses on complex, non-traditional investigations, including agent misconduct, internal matters, and other high-risk issues affecting brand integrity and compliance.
• Manages end-to-end investigations by gathering and analyzing information, conducting interviews, and synthesizing findings into clear, well-supported conclusions.
• Documents all investigative activities thoroughly in alignment with organizational and regulatory standards.
• Identifies patterns and emerging risks, providing insights to support mitigation strategies and business decisions.
• Collaborates with internal partners such as Legal, Human Resources, and Compliance.
• May coordinate with external regulatory or law enforcement agencies as needed.
• Exercises independent judgment in handling complex assignments, influencing investigative strategy, and recommending actions, while working with minimal direction and demonstrating leadership capability.

Benefits

• medical
• dental
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Senior