Become a part of our caring community and help us put health first
 

The Senior Fraud and Waste Professional (Program Integrity Lead) is responsible for overseeing the monitoring and enforcement of the Fraud, Waste, and Abuse (FWA) program. This role aims to prevent and detect potential FWA activities in accordance with state and federal regulations. The individual in this position acts as the primary liaison for the Virgina Medicaid. They coordinate all Medicaid FWA activities in Virgina to enhance the program's transparency and accountability.

The Senior Fraud and Waste Professional also conducts investigations into allegations of fraudulent and abusive practices. Their work involves handling moderately complex to complex issues, requiring an in-depth evaluation of various factors.

The Senior Fraud and Waste Professional 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. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Use your skills to make an impact
 

WORK STYLE: Remote, work at home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day, 5 days/week.

Required Qualifications

• Bachelor's Degree or equivalent years of relevant work experience in Fraud & Abuse Investigations required

• 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, Word, Excel, Access)

• Strong personal and professional ethics

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Reside in Virginia or a bordering state (preferred, not required)
  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

Work at Home Requirements

•            At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

•            Satellite, cellular and microwave connection can be used only if approved by leadership

•            Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

•            Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

•            Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability. Hire Vue (formerly Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

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 subs