Manager, Fraud and Waste

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, Managed Care, GovernmentIndustries

Requirements

Candidates must possess a Bachelor's degree and a minimum of 3 years of experience in health insurance claims or Medicare. A minimum of 3 years of experience with Fraud, Waste, and Abuse in either a Managed Care or government setting is required, along with at least 3 years of proven leadership skills and significant experience directly managing professionals. Proven knowledge in Medicare regulations, excellent PC skills (MS Excel, Access, and PowerPoint), strong communication, organizational, project management, and analytical skills are essential. Candidates must be able to analyze large amounts of data and align with Eastern Standard Time (EST) core business hours. Preferred qualifications include relevant certifications and experience in the healthcare industry, claims processing, internal investigative process development, and corporate environments.

Responsibilities

The Special Investigations Unit Manager will lead and monitor investigations of fraudulent and abusive practices, applying advanced technical knowledge to solve moderately complex problems. This role involves coordinating investigations with law enforcement authorities, leading teams in assembling evidence and documentation, and monitoring billing practices using investigational tools. The manager will prepare complex investigative and audit reports, make decisions regarding resources, approach, and tactical operations, and collaborate across departments. They will also conduct briefings and area meetings and maintain frequent contact with other managers.

Skills

Fraud

Waste

Abuse

Managed Care

Government

Health Insurance Claims

Medicare

Leadership

Investigation

Audit Reports

Law Enforcement Coordination

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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