Fraud and Waste Professional 2

The Fraud and Waste Professional 2 conducts investigations of allegations of fraudulent and abusive practices. This role involves varied work assignments that require interpretation and independent determination of appropriate courses of action.

The Fraud and Waste Professional 2 coordinates investigations with law enforcement authorities, assembles evidence and documentation to support successful adjudication, and conducts on-site audits of provider records to ensure appropriateness of billing practices. They prepare complex investigative and audit reports and understand department, segment, and organisational strategy and operating objectives.

Work Style: This is a remote position, with occasional travel to Humana's offices for training or meetings required.

Work Hours: Typical work hours are Monday-Friday, 8 hours/day, 5 days/week, in EST/CST time zones.

Responsibilities:

• Conduct investigations of allegations of fraudulent and abusive practices
• Coordinate investigations with law enforcement authorities
• Assemble evidence and documentation to support successful adjudication
• Conduct on-site audits of provider records
• Prepare complex investigative and audit reports

Requirements:

• Bachelor's degree
• 2 years of healthcare fraud investigations within Medicare
• Strong analytical skills and experience utilising AI in a professional capacity
• Knowledge of healthcare payment methodologies, claims, submissions, and payments
• Strong organisational, interpersonal, and communication skills
• Inquisitive nature with ability to analyse data to metrics
• Proficiency with MS Word, Excel, Access
• Strong personal and professional ethics

Preferred Qualifications:

• Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI)
• Experience testifying in court
• Understanding of healthcare industry, claims processing, and investigative process development
• Experience in a corporate environment and understanding of business operations

Benefits:

• Benefits starting day 1 of employment
• Competitive 401k match
• Generous Paid Time Off accrual
• Tuition Reimbursement
• Parent Leave
• Go365 perks for well-being