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

Florida, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, MedicaidIndustries

Requirements

Bachelor's Degree or equivalent years of relevant work experience in Fraud & Abuse Investigations
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
Preferred Qualifications
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

Conducts investigations of allegations of fraudulent and abusive practices
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
Begins to influence department’s strategy
Makes decisions on moderately complex to complex issues regarding technical approach for project components
Work is performed without direction and exercises considerable latitude in determining objectives and approaches to assignments

Skills

Key technologies and capabilities for this role

Fraud InvestigationsHealthcare AuditingData AnalysisMS ExcelMS WordMS AccessHealthcare Payment MethodologiesInvestigative Reporting

Questions & Answers

Common questions about this position

Is this a remote position?

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

What are the required qualifications for this role?

A Bachelor's Degree or equivalent relevant work experience in Fraud & Abuse Investigations is required, along with 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, and strong ethics.

What are the typical work hours for this position?

Typical business hours are Monday-Friday, 8 hours per day, 5 days per week.

What benefits are provided for working from home?

Humana provides telephone equipment and, for associates in California, Illinois, Montana, or South Dakota, a bi-weekly payment for internet expenses. A minimum download speed of 25 Mbps and upload speed of 10 Mbps is recommended.

What makes a strong candidate for this Senior Fraud Investigator role?

Strong candidates will have a Bachelor's degree or equivalent experience in fraud investigations, at least 2 years in healthcare fraud and auditing, plus preferred qualifications like a graduate degree, certifications such as CFE or CPC, and experience in healthcare claims processing.

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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