[Hiring] Fraud and Waste Investigator 2 @Humana

Role Description

The Fraud and Waste Professional 2 is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving South Carolina's Medicaid Program. The role includes coordinating investigations with law enforcement authorities, assembling evidence, conducting audits, and preparing complex reports.

• Analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities.
• Assemble, organize, and preserve evidence and supporting documentation for successful case resolution.
• Communicate findings clearly and professionally, both verbally and in writing.
• Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse.
• Coordinate investigations with law enforcement, regulatory agencies, and other partners.
• Follow established guidelines/procedures.
• Interpret and apply established guidelines, policies, and procedures while exercising sound judgment.
• Leverage clinical knowledge to evaluate medical necessity and appropriateness of services.
• Maintain accurate case files, audit workpapers, and documentation.
• Manage assigned investigations and audits with minimal direction.
• Partner with cross-functional teams to support fraud prevention and program integrity initiatives.
• Perform on-site audits of provider records to assess billing accuracy and compliance.
• Prepare detailed investigative summaries, audit findings, and formal reports.
• Review claims, provider billing patterns, medical records, and related documentation.
• Support organizational goals by improving program integrity and enhancing consumer experience.
• Use data analysis and performance metrics to identify trends and areas of potential risk.

Qualifications

• 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
• Strong organizational, interpersonal, and communication skills
• Inquisitive nature with ability to analyze data
• Computer literate (MS Word, Excel, Access)
• Strong personal and professional ethics
• Passionate about improving consumer experiences

Requirements

• Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) preferred
• Understanding of healthcare industry, claims processing, and investigative process development preferred
• Experience in a corporate environment and understanding of business operations preferred

Benefits

• Medical, dental, and vision benefits
• 401(k) retirement savings plan
• Paid time off, including company and personal holidays
• Paid parental and caregiver leave
• Short-term and long-term disability
• Life insurance
• Other opportunities for personal wellness

Company Description

Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company, providing services that help millions achieve their best health.