Senior Fraud and Waste Investigator-Remote/Virtual in US

at Humana in Rogers, Arkansas, United States

Job 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.


Where you Come In

Humana is needing the Sherlock Holmes of nursing for a new Senior Fraud & Waste Professional role. Do you love gathering and investigating clinical information, studying medical materials and sources in order to discover or revise facts? Do you take the initiative to go above and beyond the obvious to find the truth? Do you take great pride in presenting evidence to leadership and legal that would be key in high level decisions? Well, if you answered YES to one or more of the above you should strongly consider Humana’s Senior Fraud & Waste Professional opportunity.

  • Conducts clinical investigations of allegations of fraudulent and abusive practices that play a key role in determining provider recommendations
  • Coordinates investigation with law enforcement authorities and assembles evidence and documentation to support successful adjudication, where appropriate.
  • Conducts on-site and virtual audits of provider records ensuring appropriateness of billing practices.
  • Prepares complex investigative and audit reports as well as conducting interviews of key parties involved in a given case.

What Humana Offers

We are fortunate to offer a remote opportunity for this job. Our Fortune 100 Company values associate engagement & your well-being. We also provide excellent professional development & continued education.

Required Qualifications – What it takes to Succeed

  • Minimum of an Associate’s degree
  • Must hold an valid RN license
  • Coding certification such as CPC, CCS or CRC
  • Minimum of 1 year of healthcare experience within a fraud investigations or auditing role
  • Minimum of 1 year of experience with medical coding as well as solid knowledge of healthcare payment methodologies
  • Inquisitive nature with ability to analyze data to metrics
  • Once the health concerns effecting our country calms down have the ability to travel 25% within the US
  • We will require?full COVID vaccination for this job as we are a?healthcare?company committed to putting health and safety first for our members, patients, associates and the communities we serve.
  • If progressed to offer, you will be required to provide proof of full vaccination or documentation for a medical or religious exemption consideration where allowed by law.

Preferred Qualifications

  • Bachelor’s degree in Healthcare, Graduate degree and/or certifications (MBA, J.D., MSN, CFE, AHFI).
  • Understanding of healthcare industry, claims processing and investigative process development.
  • Experience in a corporate environment and understanding of business operations

Additional Information – How we Value You

  • Benefits starting day 1 of employment
  • Competitive 401k match
  • Generous Paid Time Off accrual
  • Tuition Reimbursement
  • Parent Leave
  • Go365 perks for well-being
  • Must have a separate room with a locked door that can be used as a home office to ensure you have absolute and continuous privacy while you work.
  • Must have accessibility to high speed DSL or cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana systems is 10M x 1M

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.

In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period of time. These requirements include access to a personal computing device with a camera, a minimum internet connection speed of 10m x 1m, and a dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the coronavirus situation evolves. The following changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and wellbeing during the hiring process.

\#ThriveTogether #WorkAtHome

Scheduled Weekly Hours


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Job Posting: JC192877162

Posted On: Sep 20, 2021

Updated On: Oct 15, 2021