TELECOMMUTE – US National
Senior Fraud and Waste Investigator — REMOTE/WORK AT HOME
Remote North Dakota
Remote North Carolina
Remote New York
Remote New Mexico
Remote New Jersey
Remote West Virginia
Remote South Dakota
Remote South Carolina
Remote Rhode Island
Remote Puerto Rico
time typeFull time
job requisition id R-289489
Humana is looking for an experienced Senior Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana’s SIU.
The Senior Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Senior Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable 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.
In order to thrive in this role, the following attributes and experience would be helpful:
Self-starter and organized
Strong interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements
Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance).
Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform
Performing Investigative research and medical record reviews
CPT code experience
Experience with testifying in Court
This role will regularly engage with all of the following:
Local, State and Federal Law Enforcement
Humana Legal and Outside Counsel
Business areas for all product lines (Medicare, Medicaid, Commercial)
Industry Trend areas
Bachelor’s degree or significant healthcare fraud and investigation experience
At least 3 …
Auditing , Analyst , Insurance , Insurance Claims
To apply for this job please visit humana.wd5.myworkdayjobs.com.