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

Humana is looking for an experienced Senior Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana’s SIU.

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.

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.

In order to thrive in this role, the following attributes and experience would be helpful:
o    Self-starter and organized
o    Strong interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements
o    Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance).  
o    Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform
o    Performing Investigative research and medical record reviews
o    CPT code experience
o    Experience with testifying in Court
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This role will regularly engage with all of the following:
o    Local, State and Federal Law Enforcement
o    Humana Legal and Outside Counsel
o    Internal Compliance
o    Market Areas
o    Clinical Teams
o    Business areas for all product lines (Medicare, Medicaid, Commercial)
o    Industry Trend areas
 

Use your skills to make an impact
 

WORK STYLE: Remote, work from home-- with up to 15% travel to attend trials, meetings, trainings, and/or conferences

WORK HOURS: Business hours are 40 hours per week, Monday-Friday, typically 8AM-5PM in the employee's time zone. Some flexibility in work scheduling is possible, depending on business needs.

Required Qualifications

• Bachelor's degree or relevant investigative experience

• At least 5 years of fraud investigations and/or auditing experience

• Strong organizational, interpersonal, and communication skills

• Inquisitive nature with ability to analyze data to metrics

• Advanced computer skills/literacy (MS Word, Excel, Access, Power Point, Power BI)

• Strong personal and professional ethics

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

• Up to 15% (local, regional, national) travel will be required

Preferred Qualifications
•    Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI)
•    Experience testifying in court
•    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

•    WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
•    A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.  
•    Satellite and Wireless Internet service is NOT allowed for this role.
•    A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional Information - How We Value You  

•    Benefits starting day 1 of employment 

•    Competitive 401k match  

•    Generous Paid Time Off accrual  

•    Tuition Reimbursement 

•    Parent Leave 

Interview Format 

As part of our hiring process, we will be using an exciting interviewin