Manager, Fraud and Waste • Special Investigations Unit - Medicaid - Humana
San Juan, PR
About the Job
Become a part of our caring community and help us put health first
The Manager, Fraud and Waste conducts investigations of allegations of fraudulent and abusive practices. The Manager, Fraud and Waste works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.
The Manager of Fraud and Waste is responsible for overseeing a wide range of investigations and audits related to waste, abuse, and fraud. This role ensures that all audits comply with federal and state Medicaid fraud, waste, and abuse guidelines. The manager collaborates with law enforcement authorities to coordinate investigations and supervises the activities of the Special Investigations Unit (SIU) to ensure accurate and timely operational and final reviews. They gather evidence and documentation to support successful adjudication when necessary. Additionally, the manager prepares detailed investigative and audit reports. Their decisions often involve resource allocation, project approaches, and tactical operations within their department. The role requires cross-departmental collaboration, conducting briefings and area meetings, and maintaining frequent contact with other managers across the department.
Use your skills to make an impact
Additional Job Description:
+ Interpret audit results and assist health plan executives in developing appropriate action plans to address identified risks.
+ Ensure compliance with all state and federal regulations regarding fraud and abuse.
+ Respond to all legal inquiries, including subpoenas and court appearances.
+ Attend federal CMS and state fraud meetings with other managed care organizations, as well as state and federal employees.
WORK STYLE: Remote/work at home with Up to 10-15% travel (local, regional, national) will be required
WORK HOURS: Core business hours are Monday-Friday, 8 hours/day, 5 days/week.
Required Qualifications
+ Bachelor's degree in Accounting, Criminal Justice, Finance, Medical Professional, Economics, Operations Management or related field or equivalent. 7+ years of related compliance and/or special investigation experience in managed care or CMS.
+ Prior health insurance claims experience
+ Demonstrated formal or informal people management
+ Excellent PC skills (including MS, Excel and Access) required.
+ Excellent communication skills, written and verbal
+ Previous operational leadership and/or progressive business consulting experience
+ Strong organizational and project management skills
+ Must be passionate about contributing to an organization focused on continuously improving consumer experiences
+ Proven FWA Managed Care (Medicaid) Investigative experience
P referred Qualifications
+ Minimum of two years of leadership experience
+ CFE (Certified Fraud Examiner) or AHFI (Accredited Healthcare Fraud Investigator)
Additional Information
+ Benefits starting day 1 of employment
+ Competitive 401k match
+ Generous Paid Time Off accrual
+ Tuition Reimbursement
+ Parental 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
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$78,400 - $107,800 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: 01-17-2025
About us
Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
The Manager, Fraud and Waste conducts investigations of allegations of fraudulent and abusive practices. The Manager, Fraud and Waste works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.
The Manager of Fraud and Waste is responsible for overseeing a wide range of investigations and audits related to waste, abuse, and fraud. This role ensures that all audits comply with federal and state Medicaid fraud, waste, and abuse guidelines. The manager collaborates with law enforcement authorities to coordinate investigations and supervises the activities of the Special Investigations Unit (SIU) to ensure accurate and timely operational and final reviews. They gather evidence and documentation to support successful adjudication when necessary. Additionally, the manager prepares detailed investigative and audit reports. Their decisions often involve resource allocation, project approaches, and tactical operations within their department. The role requires cross-departmental collaboration, conducting briefings and area meetings, and maintaining frequent contact with other managers across the department.
Use your skills to make an impact
Additional Job Description:
+ Interpret audit results and assist health plan executives in developing appropriate action plans to address identified risks.
+ Ensure compliance with all state and federal regulations regarding fraud and abuse.
+ Respond to all legal inquiries, including subpoenas and court appearances.
+ Attend federal CMS and state fraud meetings with other managed care organizations, as well as state and federal employees.
WORK STYLE: Remote/work at home with Up to 10-15% travel (local, regional, national) will be required
WORK HOURS: Core business hours are Monday-Friday, 8 hours/day, 5 days/week.
Required Qualifications
+ Bachelor's degree in Accounting, Criminal Justice, Finance, Medical Professional, Economics, Operations Management or related field or equivalent. 7+ years of related compliance and/or special investigation experience in managed care or CMS.
+ Prior health insurance claims experience
+ Demonstrated formal or informal people management
+ Excellent PC skills (including MS, Excel and Access) required.
+ Excellent communication skills, written and verbal
+ Previous operational leadership and/or progressive business consulting experience
+ Strong organizational and project management skills
+ Must be passionate about contributing to an organization focused on continuously improving consumer experiences
+ Proven FWA Managed Care (Medicaid) Investigative experience
P referred Qualifications
+ Minimum of two years of leadership experience
+ CFE (Certified Fraud Examiner) or AHFI (Accredited Healthcare Fraud Investigator)
Additional Information
+ Benefits starting day 1 of employment
+ Competitive 401k match
+ Generous Paid Time Off accrual
+ Tuition Reimbursement
+ Parental 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
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$78,400 - $107,800 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: 01-17-2025
About us
Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Source : Humana