Senior Fraud and Waste Investigator-- REMOTE/WORK AT HOME

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Job Information

Humana

Senior Fraud and Waste Investigator-- REMOTE/WORK AT HOME

in

Charleston

West Virginia

Description

Humana is looking for an experienced Senior Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU.

The Senior Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Senior Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Fraud and Waste Professional 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, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

In order to thrive in this role, the following attributes and experience would be helpful:

o Self-starter and organized

o Strong interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements

o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance).

o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform

o Performing Investigative research and medical record reviews

o CPT code experience

o Experience with testifying in Court

This role will regularly engage with all of the following:

o Local, State and Federal Law Enforcement

o Humana Legal and Outside Counsel

o Internal Compliance

o Market Areas

o Clinical Teams

o Business areas for all product lines (Medicare, Medicaid, Commercial)

o Industry Trend areas

Required Qualifications

Bachelor's degree or significant healthcare fraud and investigation experience

At least 3 years of healthcare fraud investigations and auditing experience

Knowledge of healthcare payment methodologies, claims, submissions, and payments

Strong organizational, interpersonal, and communication skills

Inquisitive nature with ability to analyze data to metrics [MH: details about working with data-including technology/software (Power BI, SQL, Excel)]

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

Ability to travel up to 5-10%, to attend trainings and meetings, as required

Business hours are 40 hours per week, Monday-Friday, typically 8AM-5PM in the employee's time zone. Some flexibility in work scheduling is possible, depending on business needs.

Preferred Qualifications

Strongly Preferred: Bilingual: Spanish

Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI)

Experience testifying in court

Understanding of healthcare industry, claims processing, and investigative process development

Experience in a corporate environment and understanding of business operations

Additional Information

COVID Vaccination Policy:

For this job, associates are required to be fully COVID vaccinated, including booster or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home.

If progressed to offer, you will be required to:

Provide proof of full vaccination, including booster, or commit to testing protocols OR  

Provide proof of applicable exemption including any required supporting documentation

Medical, religious, state and remote-only work exemptions are available.

Work at Home Requirements

WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

Satellite and Wireless Internet service is NOT allowed for this role.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional Information - How We Value You

Benefits starting day 1 of employment

Competitive 401k match

Generous Paid Time Off accrual

Tuition Reimbursement

Parent Leave

Go365 perks for well-being

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

#ThriveTogether #WorkAtHome

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com