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

Indiana, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Must reside in Indiana or a state bordering Indiana
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
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

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 OMPP PI 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
Assist in developing FWA education to train staff, providers, and subcontractors
Attend State Agency meetings
Use skills to make an impact

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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