Location
Dover, DE, United States
Posted on
May 25, 2021
Profile
Description
The Fraud and Waste Professional 2 conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Responsibilities
The Fraud and Waste Professional 2 coordinates investigation 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 complex investigative and audit reports. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Required Qualifications
Bachelor's degree
Strong clinical experience to include multiple practice areas
At least 2 years of healthcare fraud investigations and auditing experience
Knowledge of healthcare payment methodologies
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
Must have accessibility to high speed DSL or cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana systems is 10M x 1M
A dedicated home office space, with a locked door, 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
Additional Information
Scheduled Weekly Hours
40
Company info
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