Company name
Humana Inc.
Location
Sandy, UT, United States
Employment Type
Full-Time
Posted on
Jun 17, 2021
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