Senior Fraud and Waste Investigator, Special Investigations Unit - Medicaid

Humana; Myrtle Point (OR); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare company is seeking a Senior Fraud and Waste Investigator to oversee the compliance program. You will act as the primary contact for state agencies, investigate allegations, and ensure program integrity. The ideal candidate has at least 2 years of fraud investigation experience and is passionate about improving consumer experiences. This role offers a remote work option with occasional travel for meetings.

Benefits

Flexible work hours

Bi-weekly internet expense payment for certain states

Home office equipment provided

Qualifications

• Minimum 2 years of healthcare fraud investigations and auditing experience.
• Knowledge of healthcare payment methodologies.
• Computer literate with strong personal and professional ethics.

Responsibilities

• Monitor and enforce the compliance program to prevent FWA activities.
• Investigate allegations of fraud and implement corrective actions.
• Coordinate with federal, state, and local investigative agencies.

Skills

Healthcare fraud investigations

Organizational skills

Interpersonal skills

Communication skills

Data analysis

Education

Bachelor's degree

Graduate degree or certifications

Tools

MS Word

MS Excel

MS Access

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, who will oversee 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 primary point of contact for the Ohio Department of Medicaid (ODM) and other agencies such as the Medicaid Fraud Control Unit (MFCU) and 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 exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability.

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.