The Fraud and Waste Professional 2 conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Responsibilities

The Fraud and Waste Professional 2 coordinates investigation with law enforcement authorities. Assembles evidence and documentation to support successful adjudication, where appropriate. Conducts on-site audits of provider records ensuring appropriateness of billing practices. Prepares complex investigative and audit reports. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Required 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 have accessibility to high speed DSL or cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana systems is 10M x 1M

A dedicated home office space, with a locked door, lacking ongoing interruptions to protect member PHI / HIPAA information

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

Additional Information

Scheduled Weekly Hours

40

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