[Remote] Senior Fraud and Waste Investigator, Special Investigations Unit - Medicaid at Humana

Ohio, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Medicaid, InsuranceIndustries

Requirements

Must reside in Ohio
At least 2 years of 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

Responsibilities

Carry out the provisions of the compliance plan, including FWA policies and procedures
Investigate allegations of FWA and implement corrective action plans
Assess records and independently refer suspected member fraud, provider fraud, and member abuse cases to the Ohio Department of Medicaid (ODM) and other duly authorized enforcement agencies
Coordinate across all departments to encourage sensible and culturally-competent business standards
Oversee internal investigations of FWA compliance issues
Work with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve FWA contract compliance issues
Respond to FWA questions, problems, and concerns from enrollees, providers, and ODM's Program Integrity
Cooperate effectively with federal, state, and local investigative agencies on FWA cases to ensure best outcomes; work closely with internal and external auditors, financial investigators, and claims processing areas
Adequately staff and manage the program integrity investigator(s) responsible for all FWA detection programs and activities
Assist in developing FWA education to train staff, providers, and subcontractors
Attend State Agency meetings
Serve as Humana’s Program Integrity Officer, overseeing the monitoring and enforcement of the fraud, waste, and abuse (FWA) compliance program to prevent and detect potential FWA activities pursuant to state and federal rules and regulations
Act as primary point of contact for the Ohio Department of Medicaid (ODM) and other agencies such as the Medicaid Fraud Control Unit (MFCU) and coordinate all aspects of FWA activities in Ohio to increase Medicaid program transparency and accountability

Skills

Key technologies and capabilities for this role

Fraud InvestigationComplianceProgram IntegrityFWA DetectionRegulatory ComplianceInternal InvestigationsCorrective Action PlansStakeholder CoordinationAuditingClaims Processing

Questions & Answers

Common questions about this position

Is this position remote?

This is a work at home/remote position, though occasional travel to Humana's offices for training or meetings may be required.

What are the required qualifications for this role?

Candidates must reside in Ohio, have at least 2 years of healthcare fraud investigations and auditing experience, knowledge of healthcare payment methodologies, strong organizational, interpersonal, and communication skills, an inquisitive nature with data analysis ability, computer literacy in MS Word, Excel, and Access, strong ethics, and passion for improving consumer experiences.

What are the typical work hours for this job?

Typical business hours are Monday-Friday, 8 hours per day, 5 days per week, with some flexibility possible depending on business needs.

What preferred qualifications would make me stand out?

Preferred qualifications include a Bachelor's degree, graduate degree or certifications such as MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI, understanding of healthcare industry, claims processing, investigative process development, and experience in a corporate environment.

What is the salary or compensation for this position?

This information is not specified in the job description.

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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