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 :

Additional Information :

Scheduled Weekly Hours : 40

Pay Range : $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. See our https : / / www.humana.com / legal / accessibility-resources?source=Humana_Website.