Fraud and Waste Investigator
Humana
Fraud and Waste Investigator
Humana
Sells Medicare health plans and runs senior clinics
The Fraud and Waste Investigator collaborates in investigations with law enforcement authorities. Assembles evidence and documentation to support successful adjudication, where appropriate. Conducts on-site audits of provider records ensuring appropriateness of billing practices. Prepares investigative and audit reports. Begins to influence department’s strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments.
In order to thrive in this role, the following attributes and experience would be helpful:
o Self-starter and organized
o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements
o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance).
o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform
o Performing Investigative research and medical record reviews
o CPT code experience
o Experience with testifying in Court
This role will regularly engage with all of the following:
o Local, State and Federal Law Enforcement
o Humana Legal and Outside Counsel
o Internal Compliance
o Market Areas
o Clinical Teams
o Business areas for all product lines (Medicare, Medicaid, Commercial)
o Industry Trend areas
WORK STYLE: Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
WORK HOURS: Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones
Required Qualifications
• Bachelor's degree
• 2 years of healthcare fraud investigations within Medicare
• Strong analytical 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, Access
• Strong personal and professional ethics
• Must be passionate about contributing to an organization focused on continuously 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 and understanding of business operations
Additional Information
Work at Home Requirements
• WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
• A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
• Satellite and Wireless Internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
How We Value You
• Benefits starting day 1 of employment
• Competitive 401k match
• Generous Paid Time Off accrual
• Tuition Reimbursement
• Parent Leave
• Go365 perks for well-being
Interview Format
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
#ThriveTogether #WorkAtHome
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, 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
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$65,000 - $88,600 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.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.Application Deadline: 11-27-2026
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.
Humana sells health insurance paid for by government programs, chiefly Medicare Advantage plans that private insurers run for Americans 65 and older in place of traditional Medicare. It ranks among the largest Medicare Advantage insurers in the country and also runs Medicaid plans for low-income families in several states. Its CenterWell business operates senior primary care clinics, a mail-order pharmacy and home health services, so many members get care from a company the insurer owns. Medicare and states pay Humana a set monthly amount per member, and it keeps the difference between those payments and members' medical costs. Humana was founded in 1961 as a nursing home company and is based in Louisville, Kentucky.
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