Program Integrity Researcher

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The Program Integrity Researcher is responsible for reviewing, documenting, and researching incoming allegations, referrals, and requests related to potential fraud, waste, and abuse. This role supports program integrity operations by creating and maintaining accurate database records, gathering relevant information through follow-up outreach, and obtaining supporting documentation such as medical records and claims data. The position requires strong attention to detail, organizational skills, and the ability to handle sensitive information professionally and confidentially.

Our Government Contract Requires US Citizenship for this Position

KEY ACCOUNTABILITIES

40% - Review incoming referrals and documentation to ensure all relevant details are captured in the case management system.

40% - Conduct follow‑up calls to members, providers, internal partners, or other involved parties to verify information and gather additional details needed for research or case development

20% - Request and track medical records needed to support program integrity reviews and investigations. Request, obtain, and organize claims data for analysis and review. Support analysts, investigators, and leadership by preparing case information and documentation for further review

Required Qualifications

• High School Diploma
• Basic Computer Knowledge
• Experience Conducting Telephone Outreach and Follow-up Conversations
• Strong Data Entry and Documentation Skills with High Attention to Detail
• Ability to Manage Multiple Assignments and Prioritize
• Organizational and Time Management

Preferred Qualifications

• Basic Medical Claims Experience
• Experience Working with Healthcare Documentation and Databases
• Experience in Program Integrity, Healthcare, Claims Review

Additional Information

Communication

Effectively conveys information in a clear, concise, and professional manner, both verbally and in writing. Listens actively, shares relevant information with appropriate audiences, and adjusts messaging to meet the needs of different stakeholders. Builds understanding and supports collaboration through open and respectful communication.

Attention to Detail

Demonstrates accuracy and thoroughness in completing work. Carefully reviews information, identifies inconsistencies or errors, and ensures tasks, documentation, and processes are completed correctly and completely. Maintains a high standard of quality while following established requirements and procedures.

Critical Thinking

Uses logic, analysis, and sound judgment to evaluate information, solve problems, and make decisions. Identifies root causes, considers risks and alternatives, and applies facts and data to develop effective solutions. Approaches challenges thoughtfully and recommends practical next steps.

Organization

Effectively plans, prioritizes, and manages work to meet deadlines and achieve goals. Maintains orderly records, tracks multiple tasks efficiently, and uses time and resources productively. Demonstrates the ability to coordinate responsibilities in a structured and dependable manner.

Work at Home Requirements:
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member…