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The Senior Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Senior 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 Senior Fraud and Waste Professional conducts investigations for Fraud and abuse activities related to providers/beneficiaries for the TRICARE program.
Key Responsibilities
Use your skills to make an impact
Required Qualifications
Preferred Qualifications
Additional Information
This position will be working out of the Clock Tower Building, 123 East Main Street, Louisville, KY. This position offers flex hours, can work 4, 10 hour days, or 4, 9 hour days and 4 hour day on Friday.
Scheduled Weekly Hours
40
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 because he or she is a protected veteran. It is also the policy of Humanato 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.
The Senior Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Senior 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 Senior Fraud and Waste Professional conducts investigations for Fraud and abuse activities related to providers/beneficiaries for the TRICARE program.
Key Responsibilities
- Conduct analysis of claims history to determine all potential areas of Fraud and abuse by a target provider. Utilizing Microsoft Access, create queries to determine audit universe and pull a statistically valid random sample of claims to be audited. Perform audit of medical documentation, survey beneficiaries and billing staff, analyze industry standards, review TRICARE policies and procedures, and determine all state and federal regulations violated.
- Develop evidence packages to include all allegations against a subject with supporting documentation which substantiates the allegations. This package includes documentation which compares the provider to his peers via pie charts, supports each area of suspected Fraud and establishes that the entire claims history was triaged. The package outlines all written and verbal communication with the provider to obtain medical records. The allegations must be substantiated with evidence that the provider had intent to commit fraud against TRICARE. An Access database must be included with consistent audit findings for each claim in the audit. This evidence package requires excellent written communication skills as it represents allegations of fraud which is presented to law enforcement and Assistant United States Attorneys.
- Stay abreast of emerging fraud schemes and proactively data mine claims history for aberrant patterns. Research provider specialties to maintain awareness of vulnerabilities in claims payments.
- Create Fraud and abuse education for providers, beneficiaries and associates by coordinating with Marketing, Provider Relations, and Education & Development.
- Responds to Government Lead Requests, correspondence, Fraud & Abuse Hotlines and facilitate monthly staff meetings.
Use your skills to make an impact
Required Qualifications
- Our Department of Defense contract requires U.S. citizenship for this position.
- Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
- Position requires any of the following certifications or license - Registered Nurse (Bachelor of Science in Nursing (RN/BSN), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Clinical Documentation Specialist (CCDS), Certification in Healthcare Compliance (CHC), Health Care Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or JD (Juris Doctorate)
- Anti Fraud experience
- Minimum 2 years of Claims Experience
- Knowledge of healthcare payment methodologies
- Strong organizational, interpersonal, and written/verbal communication skills
- Inquisitive nature with ability to analyze data to metrics
- Computer literate (MS, Word, Excel, Access)
Preferred Qualifications
- Understanding of healthcare industry, claims processing and investigative process development.
- Experience in a corporate environment and understanding of business operations
Additional Information
This position will be working out of the Clock Tower Building, 123 East Main Street, Louisville, KY. This position offers flex hours, can work 4, 10 hour days, or 4, 9 hour days and 4 hour day on Friday.
Scheduled Weekly Hours
40
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 because he or she is a protected veteran. It is also the policy of Humanato 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.
