Become a part of our caring community and help us put health first

This Senior Fraud and Waste Investigator will serve as Humana’s Program Integrity Officer, who will oversee the monitoring and enforcement of the fraud, waste, and abuse (FWA) compliance program to prevent and detect potential FWA activities pursuant to state and federal rules and regulations. This position will act as primary point of contact for Louisiana Department of Health (LDH) and other agencies such as the Medicaid Fraud Control Unit (MFCU) and coordinate all aspects of FWA activities in Louisiana to increase Medicaid program transparency and accountability. They will report to the plan CEO and work closely with Humana’s National Claims Cost Management Vice President.

Essential Functions and 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 Louisiana Department of Health (LDH) 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 LDH FWA contract compliance issues
• Respond to FWA questions, problems, and concerns from enrollees, providers, and LDH 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

Use your skills to make an impact

WORK STYLE: Remote, MUST RESIDE IN LOUISIANA

WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day, 5 days per week.

Required Qualifications

• Must be a Louisiana resident

• Bachelor's degree

• 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

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

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.

$69,800 - $96,200 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.

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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.