Fraud and Waste Investigator

About the Role

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 involving Florida's Medicaid Program.

Responsibilities

• Conducts comprehensive investigations of reported, alleged or suspected fraud involving Florida's Medicaid Program.
• 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.

Work Style

• WORK STYLE: 100% remote/work at home.
• While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Work Hours

• Typical business hours are Monday-Friday, 8 hours/day, 5 days/week in the associate's home time zone.

Required Qualifications

• Education: Bachelor's Degree
• Experience:
  • A minimum of 2 years’ experience conducting comprehensive health care fraud investigations (Medical Coding or Healthcare (Medical Chart Review/Insurance Billing) or Internal/External Audit or Regulatory/Compliance OR Claims Investigations or Criminal Investigation/White Collar Crime).
  • Interacting with state, federal and local law enforcement agencies.
• Skills:
  • Ability to work independently with minimal supervision and manage a high volume of assignments.
  • Analytical skills and ability to make deductions; logical and sequential thinker.
  • Strong personal and professional ethics.
  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

Preferred Qualifications

• Reside in Florida
• Strong clinical experience to include multiple practice areas
• 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.

Work at Home Requirements

• Must have the ability to provide a high speed DSL or cable modem for a home office.
• Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
• A minimum standard speed for optimal performance of 25x10 (25mbps download x 10mbps upload) is required.
• Satellite and Wireless Internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue/Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

• If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview.
• If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
• If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from