Fraud and Waste Investigator

Become a part of our caring community

Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana’s SIU.

The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department’s strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments.

In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court ​

This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas

Use your skills to make an impact

WORK STYLE: 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 work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones

Required Qualifications

• Bachelor's degree

• 2 years of healthcare fraud investigations within Medicare

• Strong analytical 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 with ability to analyze data to metrics

• Proficiency with MS Word, Excel, Access

• Strong personal and professional ethics

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) • Experience testifying in court • Understanding of healthcare industry, claims processing, and investigative process development • Experience in a corporate environment and understanding of business operations

Additional Information

Work at Home Requirements

• WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense. • A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required. • Satellite and Wireless Internet service is NOT allowed for this role. • A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

How We Value You

• Benefits starting day 1 of employment

• Competitive 401k match

• Generous Paid Time Off accrual

• Tuition Reimbursement

• Parent Leave

• Go365 perks for well-being

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will…