[Remote] Senior Fraud and Waste Investigator at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Bachelor's degree
At least 5 years of fraud investigations, corporate investigations, and/or auditing experience
Strong organizational, interpersonal, and communication skills
Inquisitive nature with ability to analyze data to metrics
Advanced computer skills/literacy (MS Word, Excel, Access, Power Point, Power BI)
Strong personal and professional ethics
Passionate about contributing to an organization focused on continuously improving consumer experiences
Up to 15% (local, regional, national) travel will be required

Responsibilities

Conduct investigations of allegations of fraudulent and abusive practices
Work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors
Coordinate investigation with law enforcement authorities
Assemble evidence and documentation to support successful adjudication, where appropriate
Conduct on-site audits of provider records ensuring appropriateness of billing practices
Prepare complex investigative and audit reports
Begins to influence department’s strategy
Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction

Skills

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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