Senior Fraud & Waste Investigator

About the Role

Humana’s Special Investigations Unit is seeking a Senior Fraud & Waste Investigator to join the Oklahoma Medicaid Team. This team of Investigators conducts investigations into allegations of fraud, waste, and abuse involving providers who submit claims to Humana’s Oklahoma Medicaid line of business.

As the Senior Fraud and Waste Investigator, you will serve as Humana’s Program Integrity Officer, and will oversee 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.

Additionally, you will act as the primary point of contact for OHCA and other agencies such as the Medicaid Fraud Control Unit (MFCU) and coordinate all aspects of FWA activities in Oklahoma to increase Medicaid program transparency and accountability. You will report to the SIU Director and work closely with Humana’s Oklahoma Market.

Key Role Functions

• 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 Oklahoma Health Care Authority (OHCA) 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
• Collaborate with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve OHCA FWA contract compliance issues
• Respond to FWA questions, problems, and concerns from enrollees, providers, and OHCA 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
• Assist in developing FWA education to train staff, providers, and subcontractors
• Attend State Agency meetings

Work Style

• WORK STYLE: Remote, work at home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
• WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day, 5 days/week.

Required Qualifications

• Must be an Oklahoma resident
• 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
• Proficient with Microsoft Office (Word, Excel, etc.)
• Strong personal and professional ethics

Preferred Qualifications

• Bachelor's degree or higher
• Any applicable certifications (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

Additional Information

• To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership.
• Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.