Fraud and Waste Investigator

Humana; United States; Remote; USD 65,000 - 89,000; Full time

Job summary

An established industry player is seeking a dedicated Fraud and Waste Investigator to join their team. This role involves conducting thorough investigations into allegations of fraud and abuse within the Medicaid sector. As a key player, you will collaborate with law enforcement, prepare detailed reports, and ensure compliance with regulations. The position is remote, requiring residency in Louisiana, and offers a competitive salary along with a bonus incentive plan. Join a forward-thinking organization committed to improving health outcomes and consumer experiences. If you're passionate about making a difference in healthcare, this opportunity is perfect for you.

Benefits

Medical benefits

Dental benefits

Vision benefits

401(k) retirement savings plan

Paid time off

Short-term disability

Long-term disability

Life insurance

Qualifications

• 2+ years of healthcare fraud investigations and auditing experience.
• Strong clinical experience across multiple practice areas.

Responsibilities

• Conduct investigations into allegations of fraud within Medicaid.
• Collaborate with law enforcement and prepare audit reports.

Skills

Interview skills

Organizational skills

Interpersonal skills

Analytical skills

Communication skills

Self-starter

Education

Associate degree

Bachelor's degree

Graduate degree (MBA, J.D., MSN)

Tools

MS Word

MS Excel

MS Access

Job description

Become a part of our caring community and help us put health first
The Fraud and Waste Investigator conducts investigations into allegations of fraudulent and abusive practices within Humana's Louisiana Medicaid line of business. The Fraud and Waste Investigator's work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

The Fraud and Waste Investigator collaborates investigations with law enforcement authorities. The Fraud and Waste Investigator assembles evidence and documentation to support successful adjudication, where appropriate. The Fraud and Waste Investigator conducts on-site audits of provider records ensuring appropriateness of billing practices. The Fraud and Waste Investigator prepares investigative and audit reports. The Fraud and Waste Investigator must exercise good judgment with considerable latitude in determining objectives and approaches to assignments.

To thrive in this role, the following attributes and experience would be helpful:

• Self-starter and organized
• Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements
• Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance).

Use your skills to make an impact

WORK STYLE: Remote/Work At Home (minimal travel, MUST RESIDE IN LOUISIANA).

WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day, 5 days/week.

Required Qualifications

• Must reside in Louisiana
• Strong clinical experience to include multiple practice areas
• 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

Preferred Qualifications

• Associate or bachelor's degree
• 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

Additional Information

Work at Home Requirements

• 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.

Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability. Hire Vue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

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 be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

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 year. This 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.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.