Fraud and Waste Investigator

Fraud and Waste Professional 2

Position Overview

Become a part of our caring community and help us put health first. The Fraud and Waste Professional 2 is responsible for conducting comprehensive investigations of reported, alleged, or suspected fraud, waste, or abuse. This role involves varied work assignments that often require interpretation and independent judgment to determine the most appropriate course of action.

The Fraud and Waste Professional 2 works collaboratively with multiple departments to identify trends and analyze claims for potential fraud, waste, and abuse (FWA), ensuring accuracy, appropriate contract interpretation, and compliance with established policies and procedures. This role gathers and organizes evidence and documentation to support successful adjudication, where appropriate. The position requires experience preparing complex investigative and audit reports and presenting case outcomes and making recommendations to senior leadership.

Responsibilities include initiating, coordinating, and reviewing audits of provider records to verify billing practices and ensuring compliance with state and federal regulations. The position requires understanding department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The Fraud and Waste Professional 2 makes independent decisions regarding work methods, including in situations with ambiguity, and requires minimal direction, while following established guidelines and procedures. Use your skills to make an impact.

Requirements

• Required Qualifications:

  • Registered and/or Pharmacy Technician Certification and at least 3 years of retail, specialty, or mail order pharmacy experience or equivalent experience in FWA investigations.
  • At least 3 years of experience with pharmacy and/or medical FWA investigations.
  • In-depth knowledge of healthcare industry, claims processing, and payment methodologies.
  • Strong organizational, interpersonal, and communication skills.
  • Demonstrated ability to work independently, self-motivate, and effectively prioritize cases with minimal oversight.
  • Extensive understanding of investigative procedures.
  • Strong analytical skills with the ability to create and interpret metrics and data.
  • Proficiency in Microsoft Office, particularly Excel.
  • High standard of personal and professional ethics.
  • Willingness and ability to travel up to 15%.

• Preferred Qualifications:

  • CFE and/or AHFI Certifications.
  • Bachelor's degree and/or other professional certifications or advanced degrees.
  • Experience developing and establishing investigative processes and creating and revising policies and procedures.
  • Experience using and/or creating visualizations in Power BI for data analysis and reporting.

Responsibilities

• Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, or abuse.
• Analyze claims for potential fraud, waste, and abuse (FWA).
• Gather and organize evidence and documentation to support successful adjudication.
• Prepare complex investigative and audit reports.
• Present case outcomes and make recommendations to senior leadership.
• Initiate, coordinate, and review audits of provider records to verify billing practices.
• Ensure compliance with state and federal regulations.
• Make independent decisions regarding work methods, including in situations with ambiguity.

Employment Details

• Employment Type: Full time
• Scheduled Weekly Hours: 40
• Location Type: (Not specified in original text)

Compensation & Benefits

• Pay Range: $65,000 - $88,600 per year
• Bonus: This job is eligible for a bonus incentive plan based on company and/or individual performance.
• Benefits: Humana, Inc. and its affiliated subsidiaries offer competitive benefits that support whole-person well-being. Benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family. Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance, and many other opportunities.

Travel

• While this is a remote position, occasional travel to Humana's offices for training or meetings may be required (up to 15%).