Fraud and Waste Investigator

This is a fully remote position, open to applicants in Ohio.

📋 Description

• Execute investigations into claims of fraudulent and abusive activities.

• Collaborate with local, state, and federal law enforcement agencies on investigations.

• Gather evidence and documentation to facilitate successful adjudication when necessary.

• Perform on-site audits of provider records to verify the appropriateness of billing practices.

• Create investigative and audit reports.

• Shape department strategies.

• Make determinations on technical methods for project components.

• Establish objectives and strategies for assignments with significant independence.

• Communicate with members, providers, and industry peers.

• Interact with Humana Legal and outside counsel, Internal Compliance, market areas, clinical teams, and business sectors across Medicare, Medicaid, and Commercial product lines, as well as industry trend areas.

⛳️ Requirements

• Bachelor's degree or equivalent professional experience.

• Extensive clinical experience across various practice areas.

• Minimum of 2 years in healthcare fraud investigations and auditing.

• Familiarity with healthcare payment methodologies.

• Exceptional organizational, interpersonal, and communication abilities.

• Proficient in data analysis to metrics.

• Computer skills, including MS Word, Excel, and Access.

• Strong personal and professional ethics.

• Motivated self-starter with excellent organizational skills.

• Proficient interview skills and ability to conduct comprehensive investigations while adhering to Humana and governmental regulations.

• Capacity to collaborate with both internal and external partners, including law enforcement, Legal, and Compliance.

• Comfort with data analysis utilizing Excel, Access, and PowerBI.

• Experience in report writing and presentation development using PowerPoint or similar platforms.

• Background in investigative research and medical record review.

• Familiarity with CPT codes.

• Experience providing testimony in court.

• Ability to work from a designated area without ongoing interruptions to safeguard PHI/HIPAA information.

• Self-supplied home internet with a minimum download speed of 25 Mbps and upload speed of 10 Mbps.

• Preferred: Graduate degree and/or relevant certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI).

• Preferred: Knowledge of the healthcare industry, claims processing, and development of investigative processes.

• Preferred: Experience in a corporate setting with an understanding of business operations.

🏝️ Benefits

• Bonus incentive plan based on company and/or individual performance.

• Comprehensive medical, dental, and vision benefits.

• 401(k) retirement savings plan.

• Paid time off.

• Company and personal holidays.

• Paid parental and caregiver leave.

• Short-term and long-term disability coverage.

• Life insurance.

• Personal wellness and smart healthcare decision support.

• Occasional travel to Humana offices for training or meetings.