Fraud and Waste Investigator

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

📋 Description

• Perform thorough investigations into reported, alleged, or suspected instances of fraud, waste, and abuse concerning South Carolina's Medicaid Program.

• Collaborate with law enforcement, regulatory bodies, and both internal and external partners to coordinate investigations.

• Examine healthcare payment methods, billing practices, reimbursement frameworks, claims, provider billing trends, medical records, and associated documentation.

• Collect, organize, safeguard, and analyze evidence and supporting documents for case resolution and adjudication.

• Conduct on-site audits of provider records to evaluate billing accuracy, documentation integrity, and compliance.

• Prepare detailed investigative summaries, audit results, and formal reports.

• Present findings both verbally and in writing to diverse audiences.

• Implement guidelines, policies, and procedures while exercising judgment in uncertain situations.

• Utilize clinical knowledge to assess medical necessity, appropriateness of services, and billing practices.

• Keep precise case files, audit working papers, and regulatory documentation.

• Manage investigations and audits with minimal supervision while adhering to deadlines and quality standards.

• Collaborate with cross-functional teams on initiatives for fraud prevention, recovery efforts, and program integrity.

• Employ data analysis and performance metrics to detect trends, anomalies, and potential risks.

• Support program integrity, foster member and provider trust, and enhance consumer experience objectives.

• Report directly to the Manager of Fraud and Waste.

⛳️ Requirements

• Bachelor’s degree.

• Extensive clinical experience across various practice areas.

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

• Familiarity with healthcare payment methodologies.

• Exceptional organizational, interpersonal, and communication abilities.

• Proficient in data and metrics analysis.

• Competent in computer applications, including MS Word, Excel, and Access.

• Strong personal and professional ethical standards.

• Commitment to enhancing consumer experiences.

• Must be a resident of South Carolina.

• Preferred qualifications include a graduate degree and/or relevant certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI).

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

• Experience in a corporate setting and business operations is preferred.

• Minimum home internet speed of 25 Mbps for downloads and 10 Mbps for uploads.

• Ability to work from a dedicated space without interruptions to maintain the confidentiality of member PHI/HIPAA information.

🏝️ Benefits

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

• Medical, dental, and vision coverage.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays and personal holidays.

• Paid parental and caregiver leave.

• Short-term and long-term disability insurance.

• Life insurance coverage.

• Requirements for a dedicated remote workspace to protect member PHI/HIPAA information.

• Fully remote work opportunity for residents of South Carolina.

• Occasional travel to Humana offices for training or meetings may be necessary.