Senior Fraud & Waste Investigator (OK)

Choosegreaterpeoria; Oklahoma; Remote; USD 71,000 - 98,000; Full time

Job summary

Join Humana’s Special Investigations Unit as a Senior Fraud & Waste Investigator in Oklahoma. You'll oversee compliance programs to prevent and detect fraud, waste, and abuse, coordinating across departments and agencies to enhance Medicaid accountability. With 2+ years of experience required, this role offers a chance to make a significant impact in healthcare integrity while working from home.

Benefits

Health benefits effective day 1

401(k) retirement savings plan with employer match

Tuition assistance

Paid time off and holidays

Qualifications

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

Responsibilities

• Investigate allegations of fraud, waste, and abuse in healthcare.
• Oversee compliance programs and implement corrective actions.
• Coordinate with federal, state, and local investigative agencies.

Skills

Organizational Skills

Interpersonal Skills

Communication Skills

Analytical Skills

Education

Bachelor's degree or higher

Tools

Microsoft Office

Job description

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

Humana’s Special Investigations Unit is seeking a Senior Fraud & Waste Investigator to join the Oklahoma Medicaid Team. This team of Investigators conducts investigations into allegations of fraud, waste, and abuse involving providers who submit claims to Humana’s Oklahoma Medicaid line of business. As the Senior Fraud and Waste Investigator, you will serve as Humana’s Program Integrity Officer, and 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.

Additionally, you will act as the primary point of contact for OHCA and other agencies such as the Medicaid Fraud Control Unit (MFCU) and coordinate all aspects of FWA activities in Oklahoma to increase Medicaid program transparency and accountability. You will report to the SIU Director and work closely with Humana’s Oklahoma Market.

Key Role Functions

• 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 Oklahoma Health Care Authority (OHCA) 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

• Collaborate with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve OHCA FWA contract compliance issues

• Respond to FWA questions, problems, and concerns from enrollees, providers, and OHCA 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

• Assist in developing FWA education to train staff, providers, and subcontractors

• Attend State Agency meetings

Use your skills to make an impact

Required Qualifications

• Must be an Oklahoma resident

• 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

• Proficient with Microsoft Office (Word, Excel, etc.)

• Strong personal and professional ethics

Preferred Qualifications

• Bachelor's degree or higher

• Any applicable certifications (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 STYLE: Remote/Work at Home (minimal travel, <5%, might be required for meetings, trainings, audits, and/or conferences).

WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day, 5 days per week

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 recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Employees 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 employees 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

Humana offers a variety of benefits to promote the best health and well-being of our employees and their families. We design competitive and flexible packages to give our employees a sense of financial security—both today and in the future, including:

• Health benefits effective day 1

• Paid time off, holidays, volunteer time and jury duty pay

• Recognition pay

• 401(k) retirement savings plan with employer match

• Tuition assistance

• Scholarships for eligible dependents

• Parental and caregiver leave

• Employee charity matching program

• Network Resource Groups (NRGs)

• Career development opportunities

Our Hiring Process

As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called HireVue. HireVue Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.

If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

If you have additional questions regarding this role posting and are an Internal Candidate, please send them to the Ask A Recruiter persona by visiting go/Buzz and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.

Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from [e-mail] with instructions on how to add the information into your official application on Humana’s secure website.

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.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

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.