Fraud and Waste Investigator, Level 2

🔥 18 hours ago

🇺🇸 United States – Remote

💵 $65k - $88.6k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving South Carolina's Medicaid Program • Analyze healthcare payment methodologies, billing practices, reimbursement structures, claims, provider billing patterns, medical records, and related documentation • Assemble, organize, preserve, and analyze evidence and supporting documentation for case resolution and adjudication • Coordinate investigations with law enforcement, regulatory agencies, and internal or external partners • Conduct on-site audits of provider records to assess billing accuracy, documentation integrity, and regulatory compliance • Prepare detailed investigative summaries, audit findings, complex reports, and formal reports • Maintain accurate case files, audit workpapers, and documentation • Manage assigned investigations and audits with minimal direction while meeting deadlines and quality expectations • Partner with cross-functional teams on fraud prevention, recovery efforts, and program integrity initiatives • Use data analysis and performance metrics to identify trends, outliers, and potential risks • Communicate findings verbally and in writing to varied audiences • Apply guidelines, policies, procedures, and sound judgment in ambiguous situations • Support program integrity, member and provider trust, and consumer experience goals • Report to the Manager of Fraud and Waste

🎯 Requirements

• Bachelor's degree • Strong clinical experience across multiple practice areas • At least 2 years of healthcare fraud investigations and auditing experience • Knowledge of healthcare payment methodologies • Strong organizational, interpersonal, and communication skills • Ability to analyze data and metrics • Computer literacy, including MS Word, Excel, and Access • Strong personal and professional ethics • Passion for continuously improving consumer experiences • Preferred: Graduate degree and/or certifications such as MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, or AHFI • Preferred: Understanding of the healthcare industry, claims processing, and investigative process development • Preferred: Corporate environment and business operations experience • Work-from-home internet service with at least 25 Mbps download and 10 Mbps upload • Ability to work from a dedicated space without ongoing interruptions to protect PHI/HIPAA information

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical, dental, and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Dedicated work-from-home space • Remote work arrangement • Occasional travel to Humana offices for training or meetings