Fraud and Waste Investigator

Summary

Become a part of our caring community The Fraud and Waste Professional is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving South Carolina's Medicaid Program. The Fraud and Waste Professional 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. Responsibilities Analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings. Assemble, organize, and analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings. Assemble, organize, and preserve evidence and supporting documentation for successful case resolution and adjudication. Communicate findings clearly and professionally, both verbally and in writing, to a variety of audiences. Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving the Medicaid program. Coordinate investigations with law enforcement, regulatory agencies, and other internal or external partners, as appropriate. Follows established guidelines/procedures. Interpret and apply established guidelines, policies, and procedures while exercising sound judgment in ambiguous situations. Leverage clinical knowledge across multiple practice areas to evaluate medical necessity,appropriateness of services, and billing practices. Maintain accurate case files, audit workpapers, and documentation in accordance with departmental and regulatory standards. Manage assigned investigations and audits with minimal direction while meeting deadlines and quality expectations. Partner with cross-functional teams to support fraud prevention, recovery efforts, and program integrity initiatives. Perform on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance with applicable policies and regulations. Prepare detailed, complex investigative summaries, audit findings, and formal reports for internal leadership and external stakeholders. Review claims, provider billing patterns, medical records, and related documentation to identify potential fraud, waste, or abuse. Support organizational goals by helping improve program integrity, protecting member and provider trust, and enhancing the consumer experience. Use data analysis and performance metrics to identify trends, outliers, and areas of potential risk. preserve evidence and supporting documentation for successful case resolution and adjudication. Use your skills to make an impact.Required Qualifications Bachelor's degreeStrong clinical experience to include multiple practice areasAt least 2 years of healthcare fraud investigations and auditing experienceKnowledge of healthcare payment methodologiesStrong organizational, interpersonal, and communication skillsInquisitive nature with ability to analyze data to metricsComputer literate (MS, Word, Excel, Access)Strong personal and professional ethicsMust be passionate about contributing to an organization focused on continuously improving consumer experiencesPreferred 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 operationsReporting Structure The Fraud and Waste Professional reports to the Manager of Fraud and WasteWork Style Fully remote in the contiguous US, with occasional travel to Humana's offices for training or meetings may be required.Work Hours Typical business hours are Monday-Friday as early as a 6am start and as late as a 9am start aligned with CST or EST.Work at Home Requirements Work at Home Requirements: To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work at Home Requirements: Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Pay Range $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 Application Deadline: 11-01-2026About us 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

Job Description

Become a part of our caring community The Fraud and Waste Professional is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving South Carolina's Medicaid Program. The Fraud and Waste Professional 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. Responsibilities Analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings. Assemble, organize, and analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings. Assemble, organize, and preserve evidence and supporting documentation for successful case resolution and adjudication. Communicate findings clearly and professionally, both verbally and in writing, to a variety of audiences. Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving the Medicaid program. Coordinate investigations with law enforcement, regulatory agencies, and other internal or external partners, as appropriate. Follows established guidelines/procedures. Interpret and apply established guidelines, policies, and procedures while exercising sound judgment in ambiguous situations. Leverage clinical knowledge across multiple practice areas to evaluate medical necessity,appropriateness of services, and billing practices. Maintain accurate case files, audit workpapers, and documentation in accordance with departmental and regulatory standards. Manage assigned investigations and audits with minimal direction while meeting deadlines and quality expectations. Partner with cross-functional teams to support fraud prevention, recovery efforts, and program integrity initiatives. Perform on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance with applicable policies and regulations. Prepare detailed, complex investigative summaries, audit findings, and formal reports for internal leadership and external stakeholders. Review claims, provider billing patterns, medical records, and related documentation to identify potential fraud, waste, or abuse. Support organizational goals by helping improve program integrity, protecting member and provider trust, and enhancing the consumer experience. Use data analysis and performance metrics to identify trends, outliers, and areas of potential risk. preserve evidence and supporting documentation for successful case resolution and adjudication. Use your skills to make an impact.Required Qualifications Bachelor's degreeStrong clinical experience to include multiple practice areasAt least 2 years of healthcare fraud investigations and auditing experienceKnowledge of healthcare payment methodologiesStrong organizational, interpersonal, and communication skillsInquisitive nature with ability to analyze data to metricsComputer literate (MS, Word, Excel, Access)Strong personal and professional ethicsMust be passionate about contributing to an organization focused on continuously improving consumer experiencesPreferred 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 operationsReporting Structure The Fraud and Waste Professional reports to the Manager of Fraud and WasteWork Style Fully remote in the contiguous US, with occasional travel to Humana's offices for training or meetings may be required.Work Hours Typical business hours are Monday-Friday as early as a 6am start and as late as a 9am start aligned with CST or EST.Work at Home Requirements Work at Home Requirements: To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work at Home Requirements: Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Pay Range $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 Application Deadline: 11-01-2026About us 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