Fraud and Waste Investigator

🔥 0 minutes 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: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.Why this score:

• Just posted.
• Jobs at this company usually fill in 21 days.

Apply Now

Find Similar Remote Jobs

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 investigations of allegations of fraudulent and abusive practices • Collaborate with law enforcement authorities • Assemble evidence and documentation to support successful adjudication • Conduct on-site audits of provider records to ensure appropriate billing practices • Prepare investigative and audit reports • Influence department strategy • Make decisions regarding technical approaches for project components • Determine objectives and approaches to assignments with considerable latitude • Engage with local, state, and federal law enforcement • Collaborate with Humana Legal, outside counsel, internal Compliance, market areas, clinical teams, business areas across Medicare, Medicaid, and Commercial product lines, and industry trend areas

🎯 Requirements

• Bachelor's degree • 2 years of healthcare fraud investigations within Medicare • Strong analytical skills and experience utilizing AI in a professional capacity • Knowledge of healthcare payment methodologies, claims, submissions, and payments • Strong organizational, interpersonal, and communication skills • Inquisitive nature with ability to analyze data to metrics • Proficiency with MS Word, Excel, and Access • Strong personal and professional ethics • Passion for contributing to an organization focused on continuously improving consumer experiences • Interview skills and ability to conduct thorough investigations while maintaining compliance with Humana and governmental requirements • Ability to collaborate with internal and external partners, including Law Enforcement, Legal, and Compliance • Comfort with data analysis using Excel, Access, and PowerBI; report writing; and creating/presenting via PPT or other platform • Investigative research and medical record review experience • CPT code experience • Preferred: graduate degree and/or certifications including MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, or AHFI • Preferred: experience testifying in court • Preferred: understanding of healthcare industry, claims processing, and investigative process development • Preferred: experience in a corporate environment and understanding of business operations • Ability to provide high-speed DSL or cable modem for a home office • Minimum internet speed of 25 Mbps download and 10 Mbps upload • Satellite and wireless internet service is not allowed • Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information • Work hours aligned with EST/CST time zones

🏖️ Benefits

• Benefits starting day 1 of employment • Competitive 401k match • Generous Paid Time Off accrual • Tuition Reimbursement • Parent Leave • Go365 perks for well-being • Medical, dental and vision benefits • 401(k) retirement savings plan • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Bonus incentive plan based upon company and/or individual performance • Internet expense payment for associates or contractors who live and work from home in California

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume