Fraud and Waste Investigator
New
H
HumanaHealthcare fraud
Fully remote in the contiguous US, Typical business hours are Monday-Friday as early as a 6am start and as late as a 9am start aligned with CST or EST.Full-TimeJunior
Salary$65,000 - $88,600 per year
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Job Details
- Experience
- At least 2 years of healthcare fraud investigations and auditing experience
- Required Skills
- Data AnalysisMicrosoft AccessMicrosoft Excel
Requirements
- Bachelor's degree.
- Strong clinical experience across multiple practice areas.
- At least 2 years of healthcare fraud investigations and auditing experience.
- Knowledge of healthcare payment methodologies.
- Ability to analyze data and metrics.
- Computer literacy, including MS Word, Excel, and Access.
- Strong organizational, interpersonal, and communication skills.
- Strong personal and professional ethics.
- Graduate degree and/or certifications such as MBA, J.D., MSN, clinical certifications, CPC, CCS, CFE, or AHFI are preferred.
- Understanding of the healthcare industry, claims processing, and investigative process development is preferred.
- Corporate environment experience and understanding of business operations are preferred.
Responsibilities
- Conduct investigations of reported, alleged, or suspected fraud, waste, and abuse involving the Medicaid program.
- Review claims, provider billing patterns, medical records, and related documentation to identify potential irregularities.
- Analyze healthcare payment methodologies, billing practices, and reimbursement structures.
- Conduct on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance.
- Assemble, organize, and preserve evidence and supporting documentation for case resolution and adjudication.
- Coordinate investigations with law enforcement, regulatory agencies, and internal or external partners.
- Use data analysis and performance metrics to identify trends, outliers, and potential risks.
- Maintain accurate case files, audit workpapers, and documentation.
- Prepare investigative summaries, audit findings, and formal reports for stakeholders.
- Manage assigned investigations and audits with minimal direction while meeting deadlines and quality expectations.
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