Fraud and Waste Investigator - Work At Home Anywhere in the US

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Job Information
Humana
Fraud and Waste Investigator - Work At Home (Anywhere in the US)
in
Charlotte
North Carolina
Description
Humana is looking for an experienced 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 Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments.
In order to thrive in this role, the following attributes and experience would be helpful:
o Self-starter and organized
o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements
o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance).
o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform
o Performing Investigative research and medical record reviews
o CPT code experience
o Experience with testifying in Court
This role will regularly engage with all of the following:
o Local, State and Federal Law Enforcement
o Humana Legal and Outside Counsel
o Internal Compliance
o Market Areas
o Clinical Teams
o Business areas for all product lines (Medicare, Medicaid, Commercial)
o Industry Trend areas
Bachelor's degree or significant healthcare fraud and investigation experience
At least 1 year of healthcare fraud investigations and auditing experience
Knowledge of healthcare payment methodologies, claims, submissions, and payments
Strong organizational, interpersonal, and communication skills
Inquisitive nature with ability to analyze data to metrics
Computer literate (MS, Word, Excel, Access)
Strong personal and professional ethics
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Ability to travel up to 5-10%, to attend trainings and meetings, as required
Business hours are 40 hours per week, Monday-Friday, typically 8AM-5PM in the employee's time zone. Some flexibility in work scheduling is possible, depending on business needs.
Preferred Qualifications
Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI)
Experience testifying in court
Understanding of healthcare industry, claims processing, and investigative process development
Experience in a corporate environment and understanding of business operations
Additional Information
COVID Vaccination Policy:
For this job, associates are required to be fully COVID vaccinated, including booster or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home.
If progressed to offer, you will be required to:
Provide proof of full vaccination, including booster, or commit to testing protocols OR  
Provide proof of applicable exemption including any required supporting documentation
Medical, religious, state and remote-only work exemptions are available.
Work at Home Requirements
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Additional Information - How We Value You
Benefits starting day 1 of employment
Competitive 401k match
Generous Paid Time Off accrual
Tuition Reimbursement
Parent Leave
Go365 perks for well-being
Interview Format
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
#ThriveTogether #WorkAtHome
Scheduled Weekly Hours
40
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ****

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