Fraud and Waste Investigator - KY
The Fraud and Waste Professional investigates allegations of fraudulent and abusive practices within the healthcare sector. Work assignments often involve interpreting and making independent determinations about appropriate actions.
Responsibilities
- Coordinate investigations with law enforcement authorities.
- Assemble evidence and documentation to support successful adjudications.
- Conduct on-site audits of provider records to ensure appropriateness of billing practices.
- Prepare complex investigative and audit reports.
Requirements
- At least 3 years of healthcare fraud investigations and/or auditing experience.
- Knowledge of healthcare payment methodologies.
- Strong organizational, interpersonal, and communication skills.
- Inquisitive nature with the ability to analyze data to metrics.
- Computer literate (MS, Word, Excel, Access).
- Strong personal and professional ethics.
Preferred Qualifications
- Candidates residing in Kentucky or bordering states preferred.
- Strong clinical experience across multiple practice areas.
- Bachelor’s, graduate degree, or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI).
- Understanding of healthcare industry, claims processing, and investigative process development.
- Experience in a corporate environment and understanding of business operations.
Work Style
Remote/Work at Home (minimal travel,
Work Hours
Typical business hours are Monday-Friday, 8 hours/day, 5 days/week.
Required Qualifications
- At least 3 years of healthcare fraud investigations and/or auditing experience.
- Knowledge of healthcare payment methodologies.
- Strong organizational, interpersonal, and communication skills.
- Inquisitive nature with the ability to analyze data to metrics.
- Computer literate (MS, Word, Excel, Access).
- Strong personal and professional ethics.
Preferred Qualifications
- Candidates who reside in Kentucky or bordering states are preferred.
- Strong clinical experience to include multiple practice areas.
- Bachelor’s, graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI).
- Understanding of healthcare industry, claims processing, and investigative process development.
- Experience in a corporate environment and understanding of business operations.
Work from Home Requirements
- To ensure effective work, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
- In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Travel
While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
$65,000 - $88,600 per year
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About Us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.