Fraud and Waste Investigator

Profile

Description

The Fraud and Waste Professional 2 conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Fraud and Waste Professional 2 coordinates investigation 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 complex investigative and audit reports. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Manage a caseload of pharmacy fraud investigations.

Identify fraud schemes and trends within the Pharmacy line of business, geographic region, or across specialties.

Develop and maintain strong working relationships with the business and market offices in their assigned regions.

Collaborate with investigative researchers and other investigative teams.

Testify in criminal and civil matters as needed.

Required Qualifications

Five or more years of investigations experience. (Prior SIU or general insurance investigations, state or local law enforcement, FBI, CIA, DEA, Secret Service, OIG, General Accounting Office, MFCU, government agencies, corporate investigations, law firm, accounting firm).

Bachelor's degree from four year college/university

Extensive experience with subject interview process

Strong organizational, interpersonal, and communication skills.

Inquisitive nature.

Computer literate in Microsoft Office, with advanced Excel skills (e.g. pivot tables, macros, charts and graphs).

Strong personal and professional ethics.

Prior pharmacy knowledge, experience, and/or investigations

Preferred Qualifications

Understanding of healthcare industry, pharmacy claims processing, investigative process development, and auditing.

Claims analysis experience

Graduate degree and/or certifications (i.e., MBA, J.D., Masters in Criminal Justice, Masters in Forensic Accounting, CFE, AHFI, PharmD, RPh, CPhT, etc.).

Experience working with Medicare and Medicaid rules and regulations.

Experience in a corporate environment and understanding of business operations.

Prior healthcare fraud investigations experience

Familiarity with Federal, State, and Local law enforcement processes

Additional Information

Work at Home/Remote Requirements

Must ensure designated work area is free from distractions during work hours and virtual meetings

Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com