Fraud and Waste Investigator

The Fraud and Waste Professional is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving South Carolina's Medicaid Program.

The 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. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.

• Analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings.
• Assemble, organize, and analyze healthcare payment methodologies, billing practices, and reimbursement structures to detect irregularities and support investigative findings.
• Assemble, organize, and preserve evidence and supporting documentation for successful case resolution and adjudication.
• Communicate findings clearly and professionally, both verbally and in writing, to a variety of audiences.
• Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving the Medicaid program.
• Coordinate investigations with law enforcement, regulatory agencies, and other internal or external partners, as appropriate.
• Follows established guidelines/procedures.
• Interpret and apply established guidelines, policies, and procedures while exercising sound judgement in ambiguous situations.
• Leverage clinical knowledge across multiple practice areas to evaluate medical necessity, appropriateness of services, and billing practices.
• Maintain accurate case files, audit work papers, and documentation in accordance with departmental and regulatory standards.
• Manage assigned investigations and audits with minimal direction while meeting deadlines and quality expectations.
• Partner with cross-functional teams to support fraud prevention, recovery efforts, and program integrity initiatives.
• Perform on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance with applicable policies and regulations.
• Prepare detailed, complex investigative summaries, audit findings, and formal reports for internal leadership and external stakeholders.
• Review claims, provider billing patterns, medical records, and related documentation to identify potential fraud, waste, or abuse.
• Support organizational goals by helping improve program integrity, protecting member and provider trust, and enhancing the consumer experience.
• Use data analysis and performance metrics to identify trends, outliers, and areas of potential risk. preserve evidence and supporting documentation for successful case resolution and adjudication.

• Bachelor's degree
• Strong clinical experience to include multiple practice areas
• 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

• Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI).
• Understanding of healthcare industry, claims processing and investigative process development.
• Experience in a corporate environment and understanding of business operations

The Fraud and Waste Professional reports to the Manager of Fraud and Waste

Fully remote in the contiguous US, with occasional travel to Humana's offices for training or meetings may be required.

Typical business hours are Monday-Friday as early as a 6am start and as late as a 9am start aligned with CST or EST.

As part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers with an enhanced method for…