Fraud and Waste Investigator
$65k - $88.6k/yr+ Bonus incentive
Mid
Bachelor's, Master's, MBA, JD
Remote in USA
RemoteFully remote within the contiguous US; occasional travel to Humana offices may be required. Work hours align with CST or EST.
Risk & ComplianceFinancial Crime & AML
About the job
Requirements
- A bachelor's degree is required.
- Strong clinical experience across multiple practice areas is required.
- At least two years of healthcare fraud investigations and auditing experience are required.
- Knowledge of healthcare payment methodologies is required.
- Strong organizational, interpersonal, and communication skills are required.
- An inquisitive nature and the ability to analyze data against metrics are required.
- Computer literacy, including Microsoft Word, Excel, and Access, is required.
- Strong personal and professional ethics are required.
- The candidate must be passionate about contributing to an organization focused on continuously improving consumer experiences.
- The employee must have internet service with at least 25 Mbps download speed and 10 Mbps upload speed; wireless, wired cable, or DSL connections are suggested.
- The employee must work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information.
Responsibilities
- Conduct comprehensive investigations of reported, alleged, or suspected fraud involving South Carolina's Medicaid Program.
- Analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings.
- Assemble, organize, and preserve evidence and supporting documentation for successful case resolution and adjudication.
- Communicate findings clearly and professionally, verbally and in writing, to a variety of audiences.
- Coordinate investigations with law enforcement, regulatory agencies, and other internal or external partners, as appropriate.
- Follow established guidelines and procedures.
- Interpret and apply established guidelines, policies, and procedures while exercising sound judgment in ambiguous situations.
- Leverage clinical knowledge across multiple practice areas to evaluate medical necessity, appropriateness of services, and billing practices.
- Maintain accurate case files, audit workpapers, and documentation in accordance with departmental and regulatory standards.
- Manage assigned investigations and audits with minimal direction while meeting deadlines and quality expectations.
- Partner with cross-functional teams to support fraud prevention, recovery efforts, and program integrity initiatives.
- Perform on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance with applicable policies and regulations.
- Prepare detailed, complex investigative summaries, audit findings, and formal reports for internal leadership and external stakeholders.
- Review claims, provider billing patterns, medical records, and related documentation to identify potential fraud, waste, or abuse.
- Use data analysis and performance metrics to identify trends, outliers, and areas of potential risk.
- Support organizational goals by helping improve program integrity, protecting member and provider trust, and enhancing the consumer experience.
Desired Qualifications
- A graduate degree and/or certifications such as an MBA, J.D., MSN, clinical certifications, CPC, CCS, CFE, or AHFI is preferred.
- Understanding of the healthcare industry, claims processing, and investigative process development is preferred.
- Experience in a corporate environment and understanding of business operations are preferred.
About the company
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.
Company Size
10,001+
Company Stage
IPO
Headquarters
Louisville, Kentucky
Founded
1961
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Simplify's Take
What believers are saying
- Enrollment is surging: in July 2026 Humana affirmed about 25% individual Medicare Advantage membership growth for 2026.
- Owned clinics create clinical careers: CenterWell Senior Primary Care added 130,900 patients, up 27%, in early 2026.
- Medicaid is widening: Illinois chose Humana in June 2026 to run Medicaid coverage statewide.
What critics are saying
- Low quality scores cut Medicare bonuses: only 20% of Humana's members sat in 4-star or better plans for 2026.
- The insurer is shrinking to save margins: about 600,000 Medicare Advantage members got plan-closure notices in October 2026.
- Stock grants carry risk: in July 2026 Humana cut its 2026 GAAP earnings floor to $6.52 a share from $8.36.
What makes Humana unique
- Military families are a second market: Humana runs the Pentagon's TRICARE health plan across 24 eastern states and Washington, DC.
- Florida anchors the business: Humana's Medicare Advantage contracts there produced 14% of its 2025 revenue.
- Medicaid is a quiet second insurer: Humana covers over 1.54 million low-income members across 11 states.
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Benefits
- Health Insurance
- Dental Insurance
- Vision Insurance
- Life Insurance
- Disability Insurance
- Unlimited Paid Time Off
- Paid Vacation
- Paid Parental Leave
- Short-term Disability
- Long-term Disability
- 401(k) Retirement Plan
- 401(k) Company Match