Manager, Fraud & Waste Investigation (Nurse Audit / Review)

Manager, Fraud And Waste Investigator : Nurse Audit / Review

Become a part of our caring community and help us put health first. The Manager, Fraud and Waste Investigator : Nurse Audit / Review performs clinical audit / validation processes to ensure that medical record documentation and diagnosis coding for services rendered is complete, compliant, and accurate to support optimal reimbursement. The Manager, Nurse Audit / Review works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules, and goals. The Manager, Fraud and Waste Investigator : Nurse Audit / Review validates and interprets medical documentation to ensure capture of all relevant coding. Identifies members with high-risk CMS Hierarchical Condition Categories (HCC) and refers cases for annual follow-up care by disease management, case management, and primary care providers as appropriate for assessment / intervention. Identifies the root cause analysis of audit findings and submits recommendations for appropriate change management. Applies clinical and coding experience to conduct reviews of provider codes and billing. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.

Work Style : Remote, work at home (associates can opt to work in a local Humana office). 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.

Required Qualifications :

Registered Nurse (RN), holding an active and unrestricted license

Coding knowledge (CPC preferred, but not required)

Bachelor's Degree

3 or more years of management experience in a large corporate environment with accountability of multiple teams or processes

Excellent collaboration and communication skills

Solid understanding of process / workflow concepts

Strong research, problem-solving, and analytical skills

Comprehensive knowledge of Microsoft Office, Word, Excel, and PowerPoint

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications :

Master's Degree in Business, Finance, or related fields

Healthcare Insurance Industry knowledge

CPC preferred

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. Hire Vue (formerly Modern Hire) allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. 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.

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 : 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. $86,300 - $118,700 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.

Application Deadline : 11-13-2025

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.