About Humana


Job Category:

Risk & Compliance - Investigation


United States

Approximate Salary:

Not Specified

Position Type:

Full Time

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RN Clinical Manager

Humana - Work At Home, Florida

Posted: 11/27/2018


The Manager, Fraud and Waste conducts investigations of allegations of fraudulent and abusive practices. The Manager, Fraud and Waste works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.


The Manager, Fraud and Waste 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. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.


Required Qualifications

  • Registered Nurse with broad clinical experience
  • Bachelor's Degree in health- or business-related field
  • Coding certification from AAPC or AHIMA
  • Prior auditing experience for hospital DRG or risk adjustment
  • Prior health insurance claims experience
  • Excellent PC skills (including MS, Excel and Access) required.
  • Excellent communication skills, written and verbal
  • Previous operational leadership and/or progressive business consulting experience
  • Strong organizational and project management skills

Preferred Qualifications

  • Minimum of two years of leadership experience
  • CRC coding certification

Additional Information

Scheduled Weekly Hours


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