Fraud and Waste Investigator

About the Role

Become a part of our caring community and help us put health first. Humana Healthy Horizons in Oklahoma is seeking a Fraud and Waste Professional 2 who conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Fraud and Waste Professional 2:

• 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 & Hours

• WORK STYLE: 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.

Required Qualifications

• Must be an Oklahoma resident
• Strong clinical experience to include multiple practice areas
• 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

• Bachelor's degree
• 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

Additional Information

• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
• Scheduled Weekly Hours: 40

Pay Range

• Per Year: $65,000 - $88,600
• The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
• This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, 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.

About Us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.