Senior Fraud & Waste Investigator

Humana•Oklahoma City, OK

2d•Remote

About The Position

Become a part of our caring community and help us put health first Humana’s Special Investigations Unit is seeking a Senior Fraud & Waste Investigator to join the Oklahoma Medicaid Team. This team of Investigators conducts investigations into allegations of fraud, waste, and abuse involving providers who submit claims to Humana’s Oklahoma Medicaid line of business. As the Senior Fraud and Waste Investigator, you will serve as Humana’s Program Integrity Officer, and 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. Additionally, you will act as the primary point of contact for OHCA and other agencies such as the Medicaid Fraud Control Unit (MFCU) and coordinate all aspects of FWA activities in Oklahoma to increase Medicaid program transparency and accountability. You will report to the SIU Director and work closely with Humana’s Oklahoma Market. Key Role Functions 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 Oklahoma Health Care Authority (OHCA) 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 Collaborate with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve OHCA FWA contract compliance issues Respond to FWA questions, problems, and concerns from enrollees, providers, and OHCA 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 Assist in developing FWA education to train staff, providers, and subcontractors Attend State Agency meetings Use your skills to make an impact WORK STYLE: Remote, work at home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day, 5 days/week.

Requirements

Must be an Oklahoma resident
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
Proficient with Microsoft Office (Word, Excel, etc.)
Strong personal and professional ethics

Nice To Haves

Bachelor's degree or higher
Any applicable certifications (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 Oklahoma Health Care Authority (OHCA) 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
Collaborate with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve OHCA FWA contract compliance issues
Respond to FWA questions, problems, and concerns from enrollees, providers, and OHCA 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
Assist in developing FWA education to train staff, providers, and subcontractors
Attend State Agency meetings