# Fraud and Waste Professional

**Company**: Humana Inc.
**Location**: Remote South Carolina
**Work arrangement**: remote
**Experience**: senior
**Job type**: full-time
**Salary**: $65,000 - $88,600 per year
**Category**: Healthcare
**Industry**: Healthcare

**Apply**: https://humana.wd5.myworkdayjobs.com/en-US/Humana_External_Career_Site/job/Remote-South-Carolina/Fraud-and-Waste-Investigator_R-435686?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply
**Canonical**: https://yubhub.co/jobs/job_15399a94-3b0

## Description

The Fraud and Waste Professional is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving South Carolina's Medicaid Program.

Responsibilities:

- Analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings.

- Assemble, organize, and preserve evidence and supporting documentation for successful case resolution and adjudication.

- Communicate findings clearly and professionally, both verbally and in writing, to a variety of audiences.

- Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving the Medicaid program.

- Coordinate investigations with law enforcement, regulatory agencies, and other internal or external partners, as appropriate.

- Interpret and apply established guidelines, policies, and procedures while exercising sound judgment in ambiguous situations.

- Leverage clinical knowledge across multiple practice areas to evaluate medical necessity, appropriateness of services, and billing practices.

- Maintain accurate case files, audit workpapers, and documentation in accordance with departmental and regulatory standards.

- Manage assigned investigations and audits with minimal direction while meeting deadlines and quality expectations.

- Partner with cross-functional teams to support fraud prevention, recovery efforts, and program integrity initiatives.

- Perform on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance with applicable policies and regulations.

- Prepare detailed, complex investigative summaries, audit findings, and formal reports for internal leadership and external stakeholders.

- Review claims, provider billing patterns, medical records, and related documentation to identify potential fraud, waste, or abuse.

- Use data analysis and performance metrics to identify trends, outliers, and areas of potential risk.

Requirements:

- Bachelor's degree

- Strong clinical experience in multiple practice areas

- At least 2 years of healthcare fraud investigations and auditing experience

- Knowledge of healthcare payment methodologies

- Strong organizational, interpersonal, and communication skills

- Inquisitive nature with ability to analyze data to metrics

- Computer literate (MS Office)

- Strong personal and professional ethics

Benefits:

- Medical, dental, and vision benefits

- 401(k) retirement savings plan

- Time off (including paid time off, company and personal holidays, paid parental and caregiver leave)

- Short-term and long-term disability

- Life insurance

## Skills

### Required
- clinical experience
- healthcare payment methodologies
- investigations and auditing
- data analysis
- MS Office

### Nice to have
- graduate degree
- certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI)
- understanding of healthcare industry

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Source: [Apply at humana.wd5.myworkdayjobs.com](https://humana.wd5.myworkdayjobs.com/en-US/Humana_External_Career_Site/job/Remote-South-Carolina/Fraud-and-Waste-Investigator_R-435686?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply)