Humana Senior Fraud and Waste Investigator in Springfield, Missouri
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 coordinates investigation with law enforcement authorities. Assembles evidence and documentation to support successful adjudication, where appropriate. Prepares complex investigative and audit reports. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.
Bachelor's degree or 2 years of related experience
Active Registered Nurse (RN) license
2+ years recent experience as a CPC (Certified Professional Coder)
Minimum of 1 year of healthcare fraud investigations or auditing experience
Solid understanding of healthcare payment methodologies
Understanding of healthcare industry, claims processing and investigative process development
Ability to work independently and manage work load
Demonstrated ability to exercise solid judgment and discretion in handling and disseminating information
Excellent writing, editing, interpersonal, planning, teamwork, and communications skills Inquisitive nature with ability to analyze data to metrics
Customer-service focused and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence and commitment to profession
Proficient in MS Office applications including Word, Excel, Outlook and PowerPoint
SIU Fraud experience- strongly preferred
AHFI or CFE certification
Access and SharePoint experience
Experience in a corporate environment and understanding of business operations
Work at Home/Remote Requirements
Must ensure designated work area is free from distractions during work hours and virtual meetings
Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited).
A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required. A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required.
Scheduled Weekly Hours
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