Senior Fraud and Waste Investigator Special Investigations Unit - Medicaid

Profile

Description

The Senior Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Senior Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Fraud and Waste Professional 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. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Required Qualifications

Minimum 5 years of healthcare fraud investigations and/or auditing experience within a Medicaid Managed Care Plan

Knowledge of Florida and Wisconsin Medicaid healthcare payment methodologies

Strong organizational, interpersonal, and communication skills

Inquisitive nature with ability to analyze data to metrics

Computer literate (MS, Word, Excel)

Strong personal and professional ethics

Comprehensive knowledge of systems used to complete a FWA investigation within Humana's SIU. These systems would include at minimum: FIT, CAS MRM, CRM, PAAG, PMDM, PPirates, Pareo, and applicable power BI applications.

Preferred Qualifications

Eight plus years of experience working FWA investigations within a Medicaid Managed Care Plan

Experience working multiple states Medicaid LOB, in addition to the ones listed in the required qualifications.

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

Experience in a corporate environment and understanding of business operations

Additional Information

Work at Home Requirements

WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

Satellite and Wireless Internet service is NOT allowed for this role.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional Information - How We Value You

Benefits starting day 1 of employment

Competitive 401k match

Generous Paid Time Off accrual

Tuition Reimbursement

Parental Leave

Go365 perks for well-being

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

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.

#ThriveTogether #WorkAtHome

Scheduled Weekly Hours

40

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.

Company info

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