Fraud and Waste Investigator

Become a part of our caring community Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana’s SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department’s strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: Self-starter and organized Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform Performing Investigative research and medical record reviews CPT code experience Experience with testifying in Court This role will regularly engage with all of the following: Local, State and Federal Law Enforcement Humana Legal and Outside Counsel Internal Compliance Market Areas Clinical Teams Business areas for all product lines (Medicare, Medicaid, Commercial) Industry Trend areas Use your skills to make an impact Work at Home While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Work Hours Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones. Required Qualifications Bachelor's degree or equivalent work experience 2 years of healthcare fraud investigations and auditing experience Knowledge of healthcare payment methodologies, claims, submissions, and payments Strong organizational, interpersonal, and communication skills Inquisitive nature with ability to analyze data to metrics Proficiency with MS Word, Excel, Access Strong personal and professional ethics Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) Experience testifying in court Understanding of healthcare industry, claims processing, and investigative process development Experience in a corporate environment and understanding of business operations Work at Home Requirements WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense. A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required. Satellite and Wireless Internet service is NOT allowed for this role. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information How We Value You Benefits starting day 1 of employment Competitive 401k match Generous Paid Time Off accrual Tuition Reimbursement Parent Leave Go365 perks for well-being 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. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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 and many other opportunities. Application Deadline: 08-20-2026 About us About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com. 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. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. #J-18808-Ljbffr