[Hiring] Program Integrity Researcher @Humana

Role Description

The Program Integrity Researcher is responsible for reviewing, documenting, and researching incoming allegations, referrals, and requests related to potential fraud, waste, and abuse. This role supports program integrity operations by creating and maintaining accurate database records, gathering relevant information through follow-up outreach, and obtaining supporting documentation such as medical records and claims data. The position requires strong attention to detail, organizational skills, and the ability to handle sensitive information professionally and confidentially.

• 40% - Review incoming referrals and documentation to ensure all relevant details are captured in the case management system.
• 40% - Conduct follow-up calls to members, providers, internal partners, or other involved parties to verify information and gather additional details needed for research or case development.
• 20% - Request and track medical records needed to support program integrity reviews and investigations. Request, obtain, and organize claims data for analysis and review. Support analysts, investigators, and leadership by preparing case information and documentation for further review.

Qualifications

• High School Diploma
• Basic Computer Knowledge
• Experience Conducting Telephone Outreach and Follow-up Conversations
• Strong Data Entry and Documentation Skills with High Attention to Detail
• Ability to Manage Multiple Assignments and Prioritize
• Organizational and Time Management

Requirements

• Basic Medical Claims Experience
• Experience Working with Healthcare Documentation and Databases
• Experience in Program Integrity, Healthcare, Claims Review

Benefits

• Medical, dental and vision benefits
• 401(k) retirement savings plan
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• Short-term and long-term disability
• Life insurance
• Many other opportunities

Work at Home Requirements

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

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs.
• Humana reserves the right to require associates to upgrade their internet service if necessary.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel

While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$53,700 - $72,600 per year