Fraud and Waste Investigator

Humana; Louisville (KY); Remote; USD 65,000 - 89,000; Full time

Job summary

A leading healthcare company seeks a Fraud and Waste Professional 2 to conduct investigations of fraud, waste, and abuse. The successful candidate will analyze claims, prepare investigative reports, and work collaboratively across departments to ensure compliance with policies. This role, requiring extensive experience in pharmacy and FWA investigations, supports organizational integrity and regulatory adherence.

Benefits

Competitive medical, dental, and vision benefits

401(k) retirement savings plan

Paid time off and holidays

Short-term and long-term disability

Life insurance opportunities

Qualifications

• Minimum 3 years retail, specialty, or mail order pharmacy experience.
• Experience with pharmacy and/or medical FWA investigations.
• Demonstrated ability to prioritize tasks independently.

Responsibilities

• Conduct investigations of reported fraud, waste, or abuse.
• Collaborate with departments to analyze claims for potential FWA.
• Prepare investigative and audit reports for senior leadership.

Skills

Analytical skills

Communication skills

Organizational skills

Independence

Education

Registered and/or Pharmacy Technician Certification

Bachelor's degree (preferred)

Tools

Microsoft Excel

Power BI

Job description

Become a part of our caring community and help us put health first

The Fraud and Waste Professional 2 is responsible for conducting comprehensive investigations of reported, alleged, or suspected fraud, waste, or abuse. This role involves varied work assignments that often require interpretation and independent judgement to determine the most appropriate course of action.

The Fraud and Waste Professional 2 works collaboratively with multiple departments to identify trends and analyze claims for potential fraud, waste, and abuse (FWA), ensuring accuracy, appropriate contract interpretation, and compliance with established policies and procedures. This role gathers and organizes evidence and documentation to support successful adjudication, where appropriate. The position requires experience preparing complex investigative and audit reports and presenting case outcomes and making recommendations to senior leadership. Responsibilities include initiating, coordinating, and reviewing audits of provider records to verify billing practices and ensuring compliance with state and federal regulations. The position requires understanding department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The Fraud and Waste Professional 2 makes independent decisions regarding work methods, including in situations with ambiguity, and requires minimal direction, while following established guidelines and procedures.

Use your skills to make an impact

Required Qualifications

• Registered and/or Pharmacy Technician Certification and at least 3 years retail, specialty, or mail order pharmacy experience or equivalent experience in FWA investigations
• At least 3 years of experience with pharmacy and/or medical FWA investigations
• In-depth knowledge of healthcare industry, claims processing, and payment methodologies
• Strong organizational, interpersonal, and communication skills
• Demonstrated ability to work independently, self-motivate, and effectively prioritize cases with minimal oversight
• Extensive understanding of investigative procedures
• Strong analytical skills with the ability to create and interpret metrics and data
• Proficiency in Microsoft Office, particularly Excel
• High standard of personal and professional ethics
• Willingness and ability to travel up to 15%
  

Preferred Qualifications

• CFE and/or AHFI Certifications
• Bachelor's degree and/or other professional certifications or advanced degrees
• Experience developing and establishing investigative processes and creating and revising policies and procedures
• Experience using and/or creating visualizations in Power BI for data analysis and reporting

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$65,000 - $88,600 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our 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.Application Deadline: 07-22-2025

About us

About CenterWell Pharmacy: CenterWell Pharmacy provides convenient, safe, reliable pharmacy services and is committed to excellence and quality. Through our home delivery and over-the-counter fulfillment services, specialty, and retail pharmacy locations, we provide customers simple, integrated solutions every time. We care for patients with chronic and complex illnesses, as well as offer personalized clinical and educational services to improve health outcomes and drive superior medication adherence.About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.