Fraud and Waste Investigator

🔥 0 minutes ago

🌴 South Carolina – Remote

🌴 South Carolina – 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%

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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 • Coordinate investigations with law enforcement, regulatory agencies, and internal or external partners • 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 • Conduct on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance • Prepare complex investigative summaries, audit findings, and formal reports • Communicate findings verbally and in writing to varied audiences • Apply guidelines, policies, and procedures while exercising judgment in ambiguous situations • Leverage clinical knowledge to evaluate medical necessity, service appropriateness, and billing practices • Maintain accurate case files, audit workpapers, and regulatory documentation • Manage 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 • 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 improving consumer experiences • Must reside in South Carolina • Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) preferred • Understanding of the healthcare industry, claims processing, and investigative process development preferred • Corporate environment and business operations experience preferred • Minimum home internet speed of 25 Mbps download and 10 Mbps upload • Ability to work from a dedicated space without ongoing interruptions to protect member 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 remote workspace requirements to protect member PHI/HIPAA information • Fully remote work in South Carolina • Occasional travel to Humana offices for training or meetings may be required

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