Senior Fraud and Waste Investigator, Special Investigations Unit - Medicaid

Humana; Kentucky; Remote; USD 71,000 - 98,000; Full time

Job summary

A leading healthcare company in Kentucky is seeking a Senior Fraud and Waste Investigator to oversee the compliance program against fraud and abuse. The ideal candidate will have at least 2 years of experience in healthcare fraud investigations and strong communication skills. This position is remote with occasional travel required. The annual salary ranges from $71,100 to $97,800, and benefits include medical, 401(k), paid time off, and more.

Benefits

Medical, dental, and vision coverage

401(k) retirement savings

Paid time off

Disability and life insurance

Qualifications

• At least 2 years of healthcare fraud investigations and auditing experience.
• Knowledge of healthcare payment methodologies.
• Computer literate (MS Word, Excel, Access).

Responsibilities

• Oversee the fraud, waste, and abuse compliance program.
• Investigate allegations of fraud and implement corrective actions.
• Coordinate with Medicaid agencies for fraud-related activities.

Skills

Strong organizational skills

Interpersonal skills

Communication skills

Data analysis

Computer literacy (MS Office)

Ethical standards

Education

Bachelor's degree

Job description

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

This Senior Fraud and Waste Investigator will serve as Humana’s Program Integrity Officer, overseeing the monitoring and enforcement of the fraud, waste, and abuse (FWA) compliance program to prevent and detect potential FWA activities pursuant to state and federal rules and regulations. This position will act as the primary point of contact for the Ohio Department of Medicaid (ODM) and other agencies such as the Medicaid Fraud Control Unit (MFCU) and will coordinate all aspects of FWA activities in Ohio to increase Medicaid program transparency and accountability.

Essential Functions and Responsibilities

• Carry out the provisions of the compliance plan, including FWA policies and procedures
• Investigate allegations of FWA and implement corrective action plans
• Assess records and independently refer suspected member fraud, provider fraud, and member abuse cases to the Ohio Department of Medicaid (ODM) and other duly authorized enforcement agencies
• Coordinate across all departments to encourage sensible and culturally-competent business standards
• Oversee internal investigations of FWA compliance issues
• Work with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve FWA contract compliance issues
• Respond to FWA questions, problems, and concerns from enrollees, providers, and ODM's Program Integrity
• Cooperate effectively with federal, state, and local investigative agencies on FWA cases to ensure best outcomes; work closely with internal and external auditors, financial investigators, and claims processing areas
• Adequately staff and manage the program integrity investigator(s) responsible for all FWA detection programs and activities
• Assist in developing FWA education to train staff, providers, and subcontractors
• Attend State Agency meetings

Use your skills to make an impact

Work Style: Work at home/remote. 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 Monday–Friday, 8 hours/day, 5 days per week. Some flexibility might be possible, depending on business needs.

Required Qualifications

• Must reside in Ohio
• 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

• 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 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

$71,100 - $97,800 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 offer competitive benefits that support whole-person well-being. Benefits include medical, dental and vision coverage, 401(k) retirement savings, paid time off, holidays, volunteer time off, paid parental and caregiver leave, disability and life insurance, and more.

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 strive to help people achieve their best health and quality of life.

Equal Opportunity Employer

Humana does not 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. Humana also takes affirmative action in compliance with applicable laws to employ and advance individuals with disability or protected veteran status, and to base all employment decisions on valid job requirements.