Senior Fraud And Waste Investigator, Special Investigations Unit - Medicaid (Must Live In Ohio: Work At Home/Some Travel)

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 the Ohio Department of Medicaid (ODM) and other agencies such as the Medicaid Fraud Control Unit (MFCU) and coordinate all aspects of FWA activities in Ohio to increase Medicaid program transparency and accountability.

Responsibilities

Essential Functions and Responsibilities

• Coordinate across all departments to encourage sensible and culturally-competent business standards
• Investigate allegations of FWA and implement corrective action plans
• Assist in developing FWA education to train staff, providers, and subcontractors
• 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
• Respond to FWA questions, problems, and concerns from enrollees, providers, and ODM's Program Integrity
• Adequately staff and manage the program integrity investigator(s) responsible for all FWA detection programs and activities
• Work with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve FWA contract compliance issues
• Carry out the provisions of the compliance plan, including FWA policies and procedures
• Attend State Agency meetings
• Assess records and independently refer suspected member fraud, provider fraud, and member abuse cases to the Ohio Department of Medicaid (ODM) and other duly authorized enforcement agencies
• Oversee internal investigations of FWA compliance issues

Required Qualifications

• Supervisory or leadership experience
• Experience in healthcare, healthcare investigations, and/or risk management
• Must be a resident of Ohio

Preferred Qualifications

• Extensive knowledge and experience working with state administrative codes and regulations, Medicaid, managed care, and insurance laws and regulations
• Bachelor’s degree in Public Policy, Business, or related field
• Master’s degree in Law, Business, Healthcare, or related field
• Extensive knowledge and experience with program integrity

Additional Information

How We Value You

• Go365 perks for well-being
• Generous Paid Time Off accrual
• Tuition Reimbursement
• Benefits starting day 1 of employment
• Competitive 401k match
• Parent Leave

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

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 our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward 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 via 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 anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period of time. These requirements include access to a personal computing device with a camera, a minimum internet connection speed of 25m x 10m, and a dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the coronavirus situation evolves.

The following changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and wellbeing during the hiring process.

#ThriveTogether #WorkAtHome

Scheduled Weekly Hours

40