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.

#LI-Remote

Required Qualifications

• Must reside in Louisiana
• Healthcare fraud, waste, and abuse investigations 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)
• Strong personal and professional ethics
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Up to 10% travel within the region
• Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

Preferred Qualifications

• Bachelor’s degree
• Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI)
• Analytical background
• 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 Guidance

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• 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, 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.

Scheduled Weekly Hours