Program Integrity Researcher

About the role

Become a part of our caring community. The Program Integrity Researcher is responsible for reviewing, documenting, and researching incoming allegations, referrals, and requests related to potential fraud, waste, and abuse. This role supports program integrity operations by creating and maintaining accurate database records, gathering relevant information through follow‑up outreach, and obtaining supporting documentation such as medical records and claims data. The position requires strong attention to detail, organizational skills, and the ability to handle sensitive information professionally and confidentially. US citizenship is required for this government‑contract position.

Key Accountabilities

• Review incoming referrals and documentation to ensure all relevant details are captured in the case management system (40%).
• Conduct follow‑up calls to members, providers, internal partners, or other involved parties to verify information and gather additional details needed for research or case development (40%).
• Request and track medical records needed to support program integrity reviews and investigations; request, obtain, and organize claims data for analysis and review; support analysts, investigators, and leadership by preparing case information and documentation for further review (20%).

Required Qualifications

• High School Diploma
• Basic computer knowledge
• Experience conducting telephone outreach and follow‑up conversations
• Strong data entry and documentation skills with high attention to detail
• Ability to manage multiple assignments and prioritize
• Organizational and time‑management skills

Preferred Qualifications

• Basic medical claims experience
• Experience working with healthcare documentation and databases
• Experience in program integrity, healthcare, or claims review

Additional Information

• Communication: Conveys information clearly and professionally, both verbally and in writing; listens actively and tailors messaging to diverse stakeholders.
• Attention to Detail: Demonstrates accuracy and thoroughness, reviews information for inconsistencies, and ensures tasks and documentation meet high‑quality standards.
• Critical Thinking: Uses logic, analysis, and sound judgment to evaluate information, solve problems, and make decisions; identifies root causes and considers risks and alternatives.
• Organization: Plans, prioritizes, and manages work to meet deadlines; maintains orderly records and coordinates responsibilities in a structured, dependable manner.

Work‑at‑Home Requirements

Employees must have self‑provided internet service with a minimum download speed of 25 Mbps and upload speed of 10 Mbps (wireless, wired cable, or DSL suggested). Humana may require an upgrade if the connection is insufficient for business needs. Work must be performed from a dedicated space free from interruptions to protect member PHI/HIPAA information.

Travel

While this is a remote position, occasional travel to Humana offices for training or meetings may be required.

Scheduled Weekly Hours

40 hours per week.

Pay Range

$53,700 – $72,600 per year (estimate for full‑time employment; actual pay varies based on location, skills, experience, education, certifications, etc.).

Benefits

Humana offers competitive benefits that support whole‑person well‑being, including medical, dental, and vision coverage; a 401(k) retirement savings plan; paid time off (including holidays, parental and caregiver leave); short‑term and long‑term disability; life insurance; and many other wellness and financial programs.

About Us

Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through Humana insurance services and CenterWell healthcare services, we help millions achieve their best health by delivering the care and service they need, when they need it. Our efforts improve quality of life for people with Medicare and Medicaid, families, individuals, military personnel, and communities at large.