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Humana · 5 months ago

Senior Fraud & Waste Investigator

United States

Full-time

Remote

Mid, Senior Level

$71K/yr - $98K/yr

2+ years exp

Humana is committed to putting health first and is seeking a Senior Fraud & Waste Investigator to join their Oklahoma Medicaid Team. This role involves conducting investigations into allegations of fraud, waste, and abuse, overseeing the compliance program, and coordinating with various agencies to enhance Medicaid program transparency and accountability.

Health CareHealth InsuranceInsuranceVenture Capital

Responsibilities

Carry out the provisions of the compliance plan, including FWA policies and procedures

Investigate allegations of FWA and implement corrective action plans

Assess records and independently refer suspected member fraud, provider fraud, and member abuse cases to the Oklahoma Health Care Authority (OHCA) and other duly authorized enforcement agencies

Coordinate across all departments to encourage sensible and culturally-competent business standards

Oversee internal investigations of FWA compliance issues

Collaborate with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve OHCA FWA contract compliance issues

Respond to FWA questions, problems, and concerns from enrollees, providers, and OHCA Program Integrity

Cooperate effectively with federal, state, and local investigative agencies on FWA cases to ensure best outcomes; work closely with internal and external auditors, financial investigators, and claims processing areas

Assist in developing FWA education to train staff, providers, and subcontractors

Attend State Agency meetings

Qualification

Healthcare fraud investigationsHealthcare payment methodologiesData analysisMicrosoft OfficeInvestigative process developmentEthicsInquisitive natureExperience in corporate environmentHealthcare industryClaims processingBusiness operationsApplicable certificationsOrganizational skillsInterpersonal skillsCommunication skills