Program Integrity Researcher

Humana Inc; Northern (KY); Hybrid; USD 54,000 - 73,000; Full time

Job summary

Humana Inc. is seeking a Program Integrity Researcher for a remote Kentucky-based, full-time role. The position focuses on reviewing, documenting, and researching incoming allegations of potential fraud, waste, and abuse while maintaining accurate records and collecting supporting materials.

Candidates should have strong attention to detail, organizational skills, and the ability to handle sensitive information confidentially. Travel to Humana offices may be required occasionally.

Qualifications

• High School Diploma.
• Basic Computer Knowledge.
• Experience conducting telephone outreach and follow-up conversations.
• Strong data entry and documentation skills with high attention to detail.
• Ability to manage multiple assignments and prioritize.
• Organizational and time management.

Responsibilities

• Review incoming referrals and documentation to ensure all relevant details are captured in the case management system.
• Conduct follow-up calls to members, providers, internal partners, or other involved parties to verify information and gather additional details needed for research or case development.
• Request and track medical records needed to support program integrity reviews and investigations. Request, obtain, and organize claims data for analysis and review.
• Support analysts, investigators, and leadership by preparing case information and documentation for further review.

Skills

Attention to detail

Documentation skills

Telephone outreach

Time management

Organizational skills

Education

High School Diploma

Tools

Databases

Claims data

Job description

## Program Integrity ResearcherApply: Remote Kentucky: Full time: Posted 2 Days Ago: R-429126# **Become a part of our caring community**The Program Integrity Researcher is responsible for reviewing, documenting, and researching incoming allegations, referrals, and requests related to potential fraud, waste, and abuse. This role supports program integrity operations by creating and maintaining accurate database records, gathering relevant information through follow-up outreach, and obtaining supporting documentation such as medical records and claims data. The position requires strong attention to detail, organizational skills, and the ability to handle sensitive information professionally and confidentially.***Our Government Contract Requires US Citizenship for this Position*****KEY ACCOUNTABILITIES**40% - Review incoming referrals and documentation to ensure all relevant details are captured in the case management system.40% - Conduct follow-up calls to members, providers, internal partners, or other involved parties to verify information and gather additional details needed for research or case development20% - Request and track medical records needed to support program integrity reviews and investigations. Request, obtain, and organize claims data for analysis and review. Support analysts, investigators, and leadership by preparing case information and documentation for further review# **Use your skills to make an impact****Required Qualifications*** High School Diploma* Basic Computer Knowledge* Experience Conducting Telephone Outreach and Follow-up Conversations* Strong Data Entry and Documentation Skills with High Attention to Detail* Ability to Manage Multiple Assignments and Prioritize* Organizational and Time Management**Preferred Qualifications*** Basic Medical Claims Experience* Experience Working with Healthcare Documentation and Databases* Experience in Program Integrity, Healthcare, Claims Review**Additional Information****Communication**Effectively conveys information in a clear, concise, and professional manner, both verbally and in writing. Listens actively, shares relevant information with appropriate audiences, and adjusts messaging to meet the needs of different stakeholders. Builds understanding and supports collaboration through open and respectful communication.**Attention to Detail**Demonstrates accuracy and thoroughness in completing work. Carefully reviews information, identifies inconsistencies or errors, and ensures tasks, documentation, and processes are completed correctly and completely. Maintains a high standard of quality while following established requirements and procedures.**Critical Thinking**Uses logic, analysis, and sound judgment to evaluate information, solve problems, and make decisions. Identifies root causes, considers risks and alternatives, and applies facts and data to develop effective solutions. Approaches challenges thoughtfully and recommends practical next steps.**Organization**Effectively plans, prioritizes, and manages work to meet deadlines and achieve goals. Maintains orderly records, tracks multiple tasks efficiently, and uses time and resources productively. Demonstrates the ability to coordinate responsibilities in a structured and dependable manner.Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.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.$53,700 - $72,600 per year