Fraud and Waste Investigator

Humana Inc; Virginia (MN); Remote; USD 65,000 - 89,000; Full time

Job summary

A leading healthcare company is seeking a Fraud and Waste Investigator to conduct thorough investigations into alleged fraud involving Virginia's Medicaid Program. This role includes coordinating with law enforcement, preparing reports, and overseeing audits. Ideal candidates will bring clinical experience, auditing skills, and a commitment to ethical practices, all while working from home with occasional office visits required.

Benefits

Benefits starting day 1 of employment

Competitive 401k match

Generous Paid Time Off accrual

Tuition Reimbursement

Parent Leave

Go365 perks for well-being

Qualifications

• At least 2 years of healthcare fraud investigations and auditing experience.
• Knowledge of healthcare payment methodologies.
• Strong personal and professional ethics.

Responsibilities

• Conduct comprehensive investigations of reported, alleged, or suspected fraud.
• Coordinate investigations with law enforcement authorities.
• Prepare complex investigative and audit reports.

Skills

Clinical experience

Analytical skills

Communication skills

Interpersonal skills

Inquisitive nature

Education

Bachelor's degree

Graduate degree or certifications

Tools

MS Office Suite

Job description

Job Profile

Fraud and Waste Investigator

Job Level

Professional 2

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 involving Virgina's Medicaid Program.

The Fraud and Waste Professional 2 coordinates investigation 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 complex investigative and audit reports. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

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 8 hours/day, 5 days/week in EST.

Required Qualifications

• 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

• STRONGLY PREFERRED: Virginia residency

• Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI).

• Bachelor's degree

• Understanding of healthcare industry, claims processing and investigative process development.

• Experience in a corporate environment and understanding of business operations

Additional 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

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

Interview Format
As part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue/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 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.

#ThriveTogether #WorkAtHome

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.

Referral Bonus Information

This requisition is not eligible for a referral bonus.

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 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.