Senior Fraud and Waste Investigator, Special Investigations Unit - Medicaid

Senior Fraud And Waste Investigator

Become a part of our caring community and help us put health first. This Senior Fraud and Waste Investigator will serve as Humana's Program Integrity Officer, who will oversee the monitoring and enforcement of the fraud, waste, and abuse (FWA) compliance program. This position will act as primary point of contact for the Ohio Department of Medicaid and other agencies such as the Medicaid Fraud Control Unit and coordinate all aspects of FWA activities in Ohio to increase Medicaid program transparency and accountability.

Essential Functions and Responsibilities :

Carry out the provisions of the compliance plan, including FWA policies and procedures

Investigate allegations of FWA and implement corrective action plans

Assess records and independently refer suspected member fraud, provider fraud, and member abuse cases to the Ohio Department of Medicaid and other duly authorized enforcement agencies

Coordinate across all departments to encourage sensible and culturally-competent business standards

Oversee internal investigations of FWA compliance issues

Work with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve FWA contract compliance issues

Respond to FWA questions, problems, and concerns from enrollees, providers, and ODM's Program Integrity

Cooperate effectively with federal, state, and local investigative agencies on FWA cases to ensure best outcomes; work closely with internal and external auditors, financial investigators, and claims processing areas

Adequately staff and manage the program integrity investigator(s) responsible for all FWA detection programs and activities

Assist in developing FWA education to train staff, providers, and subcontractors

Attend State Agency meetings

Use your skills to make an impact

Work Style : Work at home / remote. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Work Hours : Typical business hours are Monday-Friday, 8 hours / day, 5 days per week. Some flexibility might be possible, depending on business needs.

Required Qualifications :

Must reside in Ohio

At least 2 years of healthcare fraud investigations and auditing experience

Knowledge of healthcare payment methodologies

Strong organizational, interpersonal, and communication skills

Inquisitive nature with ability to analyze data to metrics

Computer literate (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 :

Bachelor's degree

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

Additional Information :

Work at Home Requirements :

At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

Satellite, cellular and microwave connection can be used only if approved by leadership

Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

Humana will provide Home or Hybrid Home / Office associates with telephone equipment appropriate to meet the business requirements for their position / job.

Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Interview Format :

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability.

Scheduled Weekly Hours : 40

Pay Range : $71,100 - $97,800 per year

This 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us :

Humana Inc. (NYSE : HUM) is committed to putting health first for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.

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 complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https : / / www.humana.com / legal / accessibility-resources?source=Humana_Website.