Fraud and Waste Investigator

Ohio, United States

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Not SpecifiedCompensation

Junior (1 to 2 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Candidates must reside in Ohio or be commutable to Ohio, possess a Bachelor's degree or equivalent experience, and have at least 2 years of experience in healthcare fraud, waste, and abuse investigations or compliance. A strong understanding of healthcare payment methodologies, excellent organizational and communication skills, computer literacy with MS Word and Excel, and high personal and professional ethics are required. Preferred qualifications include a graduate degree, relevant certifications such as CFE or AHFI, and experience with Access and understanding of the healthcare industry and claims processing.

Responsibilities

The Fraud and Waste Investigator will conduct investigations into allegations of fraudulent and abusive practices, coordinate investigations with law enforcement, and assemble evidence to support adjudication. This role involves conducting on-site provider record audits to ensure billing appropriateness, preparing complex investigative and audit reports, and interpreting legislative changes. The investigator will also make independent decisions regarding work methods, follow established guidelines, and contribute to the organization's strategy by understanding department and segment objectives.

Skills

Healthcare fraud investigations

Compliance

Healthcare payment methodologies

Data analysis

MS Word

MS Excel

Auditing

Report writing

Interpersonal skills

Communication skills

Organizational skills

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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