Senior Fraud and Waste Investigator - RN with CPC Required

Profile

Description

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.

Responsibilities

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.

Required Qualifications

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

Preferred Qualifications

SIU Fraud experience- strongly preferred

AHFI or CFE certification

Access and SharePoint experience

Experience in a corporate environment and understanding of business operations

Additional Information

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

40

Company info

Humana Inc.
Website : http://www.humana.com