Fraud and Waste Investigator, Level 2

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

📋 Description

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

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

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

• Collaborate with law enforcement, regulatory bodies, and internal or external stakeholders on investigations.

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

• Draft comprehensive investigative summaries, audit findings, detailed reports, and formal documentation.

• Keep precise case files, audit workpapers, and other documentation up to date.

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

• Work in partnership with cross-functional teams on fraud prevention, recovery initiatives, and program integrity projects.

• Utilize data analysis and performance metrics to identify trends, anomalies, and potential risks.

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

• Implement guidelines, policies, procedures, and sound judgment in situations with ambiguity.

• Contribute to program integrity, building trust with members and providers, and enhancing consumer experience objectives.

• Report directly to the Manager of Fraud and Waste.

⛳️ Requirements

• Bachelor's degree required.

• Strong clinical background across various practice areas.

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

• Familiarity with healthcare payment methodologies.

• Excellent organizational, interpersonal, and communication abilities.

• Proficient in data and metrics analysis.

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

• High standards of personal and professional ethics.

• Commitment to enhancing consumer experiences.

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

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

• Preferred: Experience in a corporate environment and understanding of business operations.

• Reliable work-from-home internet connection with a minimum of 25 Mbps download and 10 Mbps upload speed.

• Capability to work from a designated area without distractions to safeguard PHI/HIPAA information.

🏝️ Benefits

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

• Comprehensive medical, dental, and vision coverage.

• 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 options.

• Dedicated workspace for remote work.

• Flexible remote work arrangements.

• Occasional travel to Humana offices for training sessions or meetings.