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 and collaborates with multiple areas of HPS to identify trends and review claims analysis for potential FWA, accuracy, contract interpretation, and compliance with policies and procedures. 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.

Required Qualifications

Pharmacy Technician Certification, with 1-3 years experience working in a pharmacy setting (Retail, Clinical, Mail Order, Specialty, etc.)

Strong understanding of pharmacy/healthcare claims, & knowledge of healthcare payment methodologies

At least 2 years of Pharmacy FWA investigations and/or auditing experience

Excellent verbal and written communication skills necessary to present information to management & other cross functional areas.

Comprehensive knowledge of Microsoft Office applications, specifically Excel for data analysis and reporting

Inquisitive nature; think outside the box attitude

Ability to self-motivate & work independently, with the ability to comprehend & analyze data to metrics, to solve problems

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

Demonstrated ability to manage multiple task and meet deadlines, and follow in a timely manner

Ability to travel up to 15% - conferences, team meetings

Preferred Qualifications

Bachelor's degree

CFE and/or AHFI Certifications

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

Experience in a corporate environment and understanding of business operations

#LI-ER1

Scheduled Weekly Hours

40

Company info

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