[Remote] Senior Fraud and Waste Investigator, Special Investigations Unit - Medicaid

Note: The job is a remote job and is open to candidates in USA. Humana Inc. is committed to putting health first and is seeking a Senior Fraud and Waste Investigator to oversee their fraud, waste, and abuse compliance program. This role involves monitoring, investigating allegations, coordinating with state agencies, and managing program integrity efforts to enhance Medicaid program accountability. 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 Ohio Department of Medicaid (ODM) 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 • Work with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve FWA contract compliance issues • Respond to FWA questions, problems, and concerns from enrollees, providers, and ODM's 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 • Adequately staff and manage the program integrity investigator(s) responsible for all FWA detection programs and activities • Assist in developing FWA education to train staff, providers, and subcontractors • Attend State Agency meetings Skills • Must reside in Ohio • 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 • Understanding of healthcare industry, claims processing and investigative process development • Experience in a corporate environment and understanding of business operations Education Requirements • Bachelor's degree • Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) Benefits • Medical, dental and vision benefits • 401(k) retirement savings plan • Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave) • Short-term and long-term disability • Life insurance Company Overview • Humana is a health insurance provider for individuals, families, and businesses. It was founded in 1964, and is headquartered in Louisville, Kentucky, USA, with a workforce of 10001+ employees. Its website is Apply tot his job Apply tot his job