[Remote] Fraud and Waste Investigator at Humana

San Antonio, Texas, United States

Apply Now

Not SpecifiedCompensation

Junior (1 to 2 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, MedicaidIndustries

Requirements

Bachelor's degree or equivalent work experience
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
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

Responsibilities

Conducting comprehensive investigations of reported, alleged or suspected fraud involving Florida's Medicaid Program
Coordinating investigation with law enforcement authorities
Assembling evidence and documentation to support successful adjudication, where appropriate
Conducting on-site audits of provider records ensuring appropriateness of billing practices
Preparing complex investigative and audit reports
Understanding department, segment, and organizational strategy and operating objectives, including their linkages to related areas
Making decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed
Following established guidelines/procedures

Skills

healthcare fraud investigations

auditing

healthcare payment methodologies

data analysis

MS Word

MS Excel

MS Access

claims processing

investigative reports

clinical experience

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.

Land your dream remote job 3x faster with AI

Try Jobo Free