Senior Fraud and Waste Investigator Special Investigations Unit - Medicaid MUST LIVE IN OHIO: WORK AT HOME/SOME TRAVEL

Profile

Description

This Senior Fraud and Waste Investigator will serve as Humana's Program Integrity Officer, who 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. This position will 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.

Responsibilities

Essential Functions and 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

Required Qualifications

Experience in healthcare, healthcare investigations, and/or risk management

Supervisory or leadership experience

Must be a resident of Ohio

Preferred Qualifications

Extensive knowledge and experience working with state administrative codes and regulations, Medicaid, managed care, and insurance laws and regulations

Bachelor's degree in Public Policy, Business, or related field

Master's degree in Law, Business, Healthcare, or related field

Extensive knowledge and experience with program integrity

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

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

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.

In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period of time. These requirements include access to a personal computing device with a camera, a minimum internet connection speed of 25m x 10m, and a dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the coronavirus situation evolves.

The following changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and wellbeing during the hiring process.

#ThriveTogether #WorkAtHome

Scheduled Weekly Hours

40

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

Company info

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