Fraud and Waste Investigator

About the role

The Fraud and Waste Professional 2 conducts investigations of allegations of fraudulent and abusive practices. Work assignments are varied and frequently require interpretation and independent determination of appropriate courses of action. The role coordinates investigations with law enforcement authorities, assembles evidence and documentation to support successful adjudication, and conducts on-site audits of provider records to ensure appropriateness of billing practices. Prepares complex investigative and audit reports. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, with minimal direction.

Responsibilities

• Conduct investigations of healthcare fraud and waste allegations
• Coordinate with law enforcement authorities as needed
• Assemble evidence and documentation to support adjudication
• Perform on-site audits of provider records to verify billing practices
• Prepare complex investigative and audit reports
• Analyze data and metrics to identify patterns or irregularities
• Testify in court when required (preferred qualification)

Requirements

• Bachelor’s degree
• 2 years of healthcare fraud investigations and auditing experience
• Knowledge of healthcare payment methodologies, claims, submissions, and payments
• Proficiency with MS Word, Excel, and Access
• Strong organizational, interpersonal, and communication skills
• Inquisitive nature with ability to analyze data
• Strong personal and professional ethics
• Passion for improving consumer experiences

Preferred Qualifications

• 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 with knowledge of business operations

Work Style

This is a remote position (work at home), though occasional travel to Humana’s offices for training or meetings may be required. Typical work hours are Monday–Friday, 8 hours/day, 5 days/week (EST/CST time zones).

Work at Home Requirements

• Must provide a high-speed DSL or cable modem for a home office (minimum 25 Mbps download / 10 Mbps upload)
• Satellite and wireless internet service are not allowed
• Dedicated workspace free from ongoing interruptions to protect member PHI/HIPAA information
• Associates in California will receive payment for internet expenses

Benefits

• Benefits starting on day 1 of employment
• Competitive 401k match
• Generous paid time off accrual
• Tuition reimbursement
• Parent leave
• Go365 wellness perks
• Medical, dental, and vision benefits
• Short-term and long-term disability
• Life insurance

Pay

The pay range for this full-time (40 hours per week) position is $65,000 – $88,600 per year. Geographic location and individual qualifications may affect compensation. This role is also eligible for a bonus incentive plan based on company and/or individual performance.

Schedule

Scheduled weekly hours: 40 (Monday–Friday, 8 hours/day).