Fraud and Waste Investigator

Become a part of our caring community and help us put health first reputed company is looking for an reputed company Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you reputed company on solving problems and thinking reputed company the reputed company? Are you self-driven and enjoy being proactive? But, most of reputed company 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 reputed company’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 reputed company to reputed company 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 reputed company in determining objectives and approaches to assignments. In order to reputed company in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with reputed company and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (reputed company, Access, PowerBI), report writing, and creating/presenting reputed company PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with reputed company of the following: o Local, State and Federal Law Enforcement o reputed company Legal and reputed company Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for reputed company product lines (Medicare, Medicaid, Commercial) o Industry Trend areas Use your skills to reputed company an impact WORK STYLE: Work at Home. While this is a remote position, occasional travel to reputed company'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
• 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 reputed company, reputed company, 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, reputed company, 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

Additional Information 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

Interview Format As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides reputed company of recruiters and hiring managers an enhanced method for decision-making. If you are selected to move reputed company from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions reputed company your phone. You should anticipate this interview to take approximately 10-15 minutes. If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last reputed company from 5-10 minutes. Your recorded interview(s) reputed company text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving reputed company to next round of interviews. #ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to reputed company's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting reputed company pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or reputed company based on geographic location and individual pay will vary based on demonstrated job reputed company 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 reputed company, Inc. and its affiliated subsidiaries (collectively, “reputed company”) 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 reputed company of work. Among our benefits, reputed company provides 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 and many other opportunities. Application Deadline: 12-29-2025 About us reputed company Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our reputed company insurance services and reputed company healthcare services, we reputed company it easier for the millions of people we serve to reputed company their best health – delivering the care and service they need, reputed company they need it. These efforts are leading to a reputed company quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. Equal Opportunity Employer It is the policy of reputed company not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national reputed company, age, marital status, genetic information, disability or protected veteran status. It is also the policy of reputed company 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 reputed company reputed company employment decisions only on valid job requirements. This policy shall apply to reputed company 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 reputed company levels of employment. Apply tot his job Apply To this Job