Senior Fraud and Waste Investigator Employee

Humana

Employee

TELECOMMUTE – US National

3/8/23

Job Description

Senior Fraud and Waste Investigator — REMOTE/WORK AT HOME

locations

Remote Wisconsin

Remote Oklahoma

Remote Ohio

Remote North Dakota

Remote North Carolina

Remote New York

Remote New Mexico

Remote New Jersey

Remote Nebraska

Remote Montana

Remote Missouri

Remote Mississippi

Remote Minnesota

Remote Michigan

Remote Massachusetts

Remote Maryland

Remote Maine

Remote Louisiana

Remote Kansas

Remote Iowa

Remote Indiana

Remote Illinois

Remote Idaho

Remote Hawaii

Remote Georgia

Remote Florida

Remote Delaware

Remote Connecticut

Remote Colorado

Remote California

Remote Arkansas

Remote Arizona

Remote Alaska

Remote Alabama

Remote West Virginia

Remote Washington

Remote Virginia

Remote Vermont

Remote Utah

Remote Texas

Remote Tennessee

Remote South Dakota

Remote South Carolina

Remote Rhode Island

Remote Puerto Rico

Remote Pennsylvania

Remote Oregon

time typeFull time

job requisition id R-289489

Description

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.

Responsibilities

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

Internal Compliance

Market Areas

Clinical Teams

Business areas for all product lines (Medicare, Medicaid, Commercial)

Industry Trend areas

Required Qualifications

Bachelor’s degree or significant healthcare fraud and investigation experience

At least 3 …

Auditing , Analyst , Insurance , Insurance Claims

US National