[Remote] Fraud and Waste Investigator at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Junior (1 to 2 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Bachelor's degree or equivalent work experience
Minimum 2 years of investigative and/or claims 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
Ability to travel up to 5%, to attend trainings and meetings, as required
Work at home requirements: minimum download speed of 25 Mbps and upload speed of 10 Mbps (wireless, wired cable or DSL suggested; satellite, cellular, microwave only if approved); work from a dedicated space lacking ongoing interruptions to protect PHI/HIPAA

Responsibilities

Conducts investigations of allegations of fraudulent and abusive practices
Coordinates investigation with internal and external entities including compliance, internal business partners, and law enforcement
Assembles evidence and documentation to support successful adjudication, where appropriate
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

Skills

Key technologies and capabilities for this role

investigationsfraud detectionclaims processinghealthcare payment methodologiesorganizational skillsinterpersonal skillscommunication 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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