Humana

About Humana

 

Job Category:

Risk & Compliance - Investigation

Country:

United States

Approximate Salary:

Not Specified

Position Type:

Full time

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Fraud and Waste Investigator

Humana - Work At Home, Wisconsin

Posted: 07/4/2018

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.

               

Required Qualifications

  • Bachelor's degree
  • Strong clinical experience to include multiple practice areas
  • Minimum 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, 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).
  • Understanding of healthcare industry, claims processing and investigative process development.
  • Experience in a corporate environment and understanding of business operations

Additional Information

Scheduled Weekly Hours

40

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