[Hiring] Fraud and Waste Investigator @Humana

Role Description

The Fraud and Waste Professional 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 on-site audits, and preparing complex reports.

• Analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings.
• Assemble, organize, and preserve evidence and supporting documentation for successful case resolution and adjudication.
• Communicate findings clearly and professionally, both verbally and in writing, to a variety of audiences.
• Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving the Medicaid program.
• Coordinate investigations with law enforcement, regulatory agencies, and other internal or external partners, as appropriate.
• Follow established guidelines/procedures.
• Interpret and apply established guidelines, policies, and procedures while exercising sound judgment in ambiguous situations.
• Leverage clinical knowledge across multiple practice areas to evaluate medical necessity, appropriateness of services, and billing practices.
• Maintain accurate case files, audit workpapers, and documentation in accordance with departmental and regulatory standards.
• Manage assigned investigations and audits with minimal direction while meeting deadlines and quality expectations.
• Partner with cross-functional teams to support fraud prevention, recovery efforts, and program integrity initiatives.
• Perform on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance with applicable policies and regulations.
• Prepare detailed, complex investigative summaries, audit findings, and formal reports for internal leadership and external stakeholders.
• Review claims, provider billing patterns, medical records, and related documentation to identify potential fraud, waste, or abuse.
• Support organizational goals by helping improve program integrity, protecting member and provider trust, and enhancing the consumer experience.
• Use data analysis and performance metrics to identify trends, outliers, and areas of potential risk.

Qualifications

• Bachelor's degree
• Strong clinical experience to include 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 to metrics
• Computer literate (MS, Word, Excel, Access)
• Strong personal and professional ethics
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Must reside in South Carolina

Preferred Qualifications

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

Work Style

• Fully remote in South Carolina, with occasional travel to Humana's offices for training or meetings may be required.

Work Hours

• Typical business hours are Monday-Friday as early as a 6am start and as late as a 9am start aligned with CST or EST.

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.

• $65,000 - $88,600 per year
• This job is eligible for a bonus incentive plan based upon company and/or individual performance.

Description of 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

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.