Senior Fraud and Waste Investigator

Profile

Description

Humana is needing the Sherlock Holmes of nursing for a new Senior Fraud & Waste Professional role. Do you love gathering and investigating clinical information, studying medical materials and sources in order to discover or revise facts? Do you take the initiative to go above and beyond the obvious to find the truth? Do you take great pride in presenting evidence to leadership and legal that would be key in high level decisions? Well, if you answered YES to one or more of the above you should strongly consider Humana's Senior Fraud & Waste Professional opportunity.

Responsibilities


Conducts clinical investigations of allegations of fraudulent and abusive practices that play a key role in determining provider recommendations
Coordinates investigation with law enforcement authorities and assembles evidence and documentation to support successful adjudication, where appropriate.
Conducts on-site and virtual audits of provider records ensuring appropriateness of billing practices.
Prepares complex investigative and audit reports as well as conducting interviews of key parties involved in a given case.


Required Qualifications


Bachelor's degree in Healthcare or equivalent years of experience within a similar role
Must hold an valid RN license
2 years of healthcare experience within a fraud investigations or auditing role
1 years of experience with medical coding as well as solid knowledge of healthcare payment methodologies
Inquisitive nature with ability to analyze data to metrics
Once the health concerns effecting our country calms down have the ability to travel 25% within the US


Work at Home Requirements


Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information


Preferred Qualifications


Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI).
Understanding of healthcare industry, claims processing and investigative process development.
Experience in a corporate environment and understanding of business operations


Scheduled Weekly Hours

40

Company info

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