Senior Fraud and Waste Investigator

Humana Inc; Virginia (MN); Remote; USD 71,000 - 98,000; Full time

Job summary

Join a leading healthcare company as a Senior Fraud and Waste Investigator, where you will oversee the Fraud, Waste, and Abuse program. This remote role requires a Bachelor's degree and significant experience in healthcare investigations. You will be responsible for conducting investigations, coordinating with law enforcement, and ensuring compliance with regulations. If you have strong analytical and communication skills, this is your chance to make a meaningful impact.

Qualifications

• 3+ years in healthcare investigations, end-to-end.
• Experience with large datasets and decision-making.

Responsibilities

• Oversee FWA program monitoring and enforcement.
• Conduct investigations into fraudulent practices.
• Coordinate with law enforcement and prepare audit reports.

Skills

Communication

Analytical Skills

Detail Oriented

Education

Bachelor’s degree or higher

Job description

Job Profile

Senior Fraud and Waste Investigator

Job Level

Senior Professional

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

The Senior Fraud and Waste Professional (Program Integrity Lead) is responsible for overseeing the monitoring and enforcement of the Fraud, Waste, and Abuse (FWA) program. This role aims to prevent and detect potential FWA activities in accordance with state and federal regulations. The individual in this position acts as the primary liaison for the Virgina Medicaid. They coordinate all Medicaid FWA activities in Virgina to enhance the program's transparency and accountability.

The Senior Fraud and Waste Professional also conducts investigations into allegations of fraudulent and abusive practices. Their work involves handling moderately complex to complex issues, requiring an in-depth evaluation of various factors.

The Senior Fraud and Waste Professional 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. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Use your skills to make an impact

WORK STYLE: 100% remote/work at home

WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day, 5 days/week in the associate's home time zone.

Required Qualifications

• Bachelor’s degree or higher

• At least three years’ experience in Health care investigations working an investigation end-to-end (experience with government referrals, on-site visits, collaborating with law enforcement, testifying, etc.)

• Experience with manipulating and analyzing large datasets

• Ability to be concise, independent and provide defensible decisions in high-pressure situations

• Detail oriented with excellent communication skills (oral presentations and written) and interpersonal skills

Preferred Qualifications

• STRONGLY PREFERRED: Virginia resident

• Medicaid experience/expertise

• 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 (formerly Modern Hire 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.$71,100 - $97,800 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.