Senior Fraud and Waste Investigator

Senior Fraud And Waste Professional (Program Integrity Lead)

The Senior Fraud and Waste Professional (Program Integrity Lead) is responsible for overseeing the monitoring and enforcement of the Fraud, Waste, and Abuse (FWA) program. This role aims to prevent and detect potential FWA activities in accordance with state and federal regulations. The individual in this position acts as the primary liaison for the Virginia Medicaid. They coordinate all Medicaid FWA activities in Virginia to enhance the program's transparency and accountability. The Senior Fraud and Waste Professional also conducts investigations into allegations of fraudulent and abusive practices. Their work involves handling moderately complex to complex issues, requiring an in-depth evaluation of various factors.

The Senior Fraud and Waste Professional coordinates investigation with law enforcement authorities. Assembles evidence and documentation to support successful adjudication, where appropriate. Conducts on-site audits of provider records ensuring appropriateness of billing practices. 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.

Work Style : Remote, work at home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Work Hours : Typical business hours are Monday-Friday, 8 hours / day, 5 days / week.

Required Qualifications

• Bachelor's Degree or equivalent years of relevant work experience in Fraud & Abuse Investigations required
• 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

Interview Format : As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability. Hire Vue (formerly Modern Hire) allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

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.

Scheduled Weekly Hours : 40

Pay Range : $71,100 - $97,800 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.

Application Deadline : 11-13-2025

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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements.