Fraud and Waste Investigator

Humana

. Conduct investigations of allegations of fraudulent and abusive practices .

Posted 11/12/2026full-timeRemote • United StatesJuniorMid-Level💰 $65,000 - $88,600 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare fraud investigations, particularly within Medicare, with strong analytical skills and proficiency in data analysis tools such as Excel and PowerBI. Capable of collaborating with law enforcement and legal teams while maintaining compliance with regulatory standards.

Highest-signal resume keywords

Healthcare Fraud InvestigationsData Analysis Using Excel and PowerBICollaboration With Law EnforcementInvestigative Research ExperienceKnowledge of Healthcare Payment Methodologies

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Healthcare Fraud InvestigationsData Analysis Using ExcelData Analysis Using PowerBICPT Code ExperienceInvestigative ResearchMedical Record ReviewReport WritingAudit PreparationEvidence AssemblyBilling Practices Auditing

Soft Skills

Strong Analytical SkillsOrganizational SkillsInterpersonal SkillsCommunication SkillsInquisitive Nature

Tools & Technologies

MS WordMS ExcelMS AccessPowerBIPPT

Certifications & Qualifications

MBAJ.D.MSNClinical CertificationsCPCCCSCFEAHFI

Industry Keywords

MedicareMedicaidHealthcare Payment MethodologiesClaims ProcessingComplianceFraudulent PracticesAbusive PracticesInvestigative Process DevelopmentConsumer Experience ImprovementPHI/HIPAA Compliance

About the role

Key responsibilities & impact

Conduct investigations of allegations of fraudulent and abusive practices
Collaborate with law enforcement authorities
Assemble evidence and documentation to support successful adjudication
Conduct on-site audits of provider records to ensure appropriate billing practices
Prepare investigative and audit reports
Influence department strategy
Make decisions regarding technical approaches for project components
Determine objectives and approaches to assignments with considerable latitude
Engage with local, state, and federal law enforcement
Collaborate with Humana Legal, outside counsel, internal Compliance, market areas, clinical teams, business areas across Medicare, Medicaid, and Commercial product lines, and industry trend areas

Requirements

What you’ll need

Bachelor's degree
2 years of healthcare fraud investigations within Medicare
Strong analytical skills and experience utilizing AI in a professional capacity
Knowledge of healthcare payment methodologies, claims, submissions, and payments
Strong organizational, interpersonal, and communication skills
Inquisitive nature with ability to analyze data to metrics
Proficiency with MS Word, Excel, and Access
Strong personal and professional ethics
Passion for contributing to an organization focused on continuously improving consumer experiences
Interview skills and ability to conduct thorough investigations while maintaining compliance with Humana and governmental requirements
Ability to collaborate with internal and external partners, including Law Enforcement, Legal, and Compliance
Comfort with data analysis using Excel, Access, and PowerBI; report writing; and creating/presenting via PPT or other platform
Investigative research and medical record review experience
CPT code experience
Preferred: graduate degree and/or certifications including MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, or AHFI
Preferred: experience testifying in court
Preferred: understanding of healthcare industry, claims processing, and investigative process development
Preferred: experience in a corporate environment and understanding of business operations
Ability to provide high-speed DSL or cable modem for a home office
Minimum internet speed of 25 Mbps download and 10 Mbps upload
Satellite and wireless internet service is not allowed
Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information
Work hours aligned with EST/CST time zones

Benefits

Comp & perks

Benefits starting day 1 of employment
Competitive 401k match
Generous Paid Time Off accrual
Tuition Reimbursement
Parent Leave
Go365 perks for well-being
Medical, dental and vision benefits
401(k) retirement savings plan
Company and personal holidays
Paid parental and caregiver leave
Short-term and long-term disability
Life insurance
Bonus incentive plan based upon company and/or individual performance
Internet expense payment for associates or contractors who live and work from home in California