Fraud and Waste Investigator

Humana

. Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving South Carolina's Medicaid Program .

Posted 11/2/2026full-timeRemote • South Carolina • 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 and auditing, with strong analytical skills to assess billing practices and compliance. Proficient in managing investigations while collaborating with cross-functional teams to enhance program integrity and consumer trust.

Highest-signal resume keywords

Healthcare Fraud InvestigationsData AnalysisHealthcare Payment MethodologiesClinical ExperienceAuditing Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Fraud InvestigationAuditingData AnalysisBilling Practices AnalysisEvidence AnalysisHealthcare ComplianceClaims ProcessingDocumentation IntegrityInvestigative ReportingPerformance Metrics

Soft Skills

Organizational SkillsInterpersonal SkillsCommunication SkillsEthicsJudgment

Tools & Technologies

MS WordMS ExcelMS Access

Certifications & Qualifications

MBAJ.D.MSNClinical CertificationsCPCCCSCFEAHFI

Industry Keywords

Medicaid ProgramFraud PreventionProgram IntegrityConsumer ExperienceHealthcare Industry

About the role

Key responsibilities & impact

Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving South Carolina's Medicaid Program
Coordinate investigations with law enforcement, regulatory agencies, and internal or external partners
Analyze healthcare payment methodologies, billing practices, reimbursement structures, claims, provider billing patterns, medical records, and related documentation
Assemble, organize, preserve, and analyze evidence and supporting documentation for case resolution and adjudication
Conduct on-site audits of provider records to assess billing accuracy, documentation integrity, and compliance
Prepare complex investigative summaries, audit findings, and formal reports
Communicate findings verbally and in writing to varied audiences
Apply guidelines, policies, and procedures while exercising judgment in ambiguous situations
Leverage clinical knowledge to evaluate medical necessity, service appropriateness, and billing practices
Maintain accurate case files, audit workpapers, and regulatory documentation
Manage investigations and audits with minimal direction while meeting deadlines and quality expectations
Partner with cross-functional teams on fraud prevention, recovery efforts, and program integrity initiatives
Use data analysis and performance metrics to identify trends, outliers, and potential risks
Support program integrity, member and provider trust, and consumer experience goals
Report to the Manager of Fraud and Waste

Requirements

What you’ll need

Bachelor's degree
Strong clinical experience across 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
Ability to analyze data and metrics
Computer literacy, including MS Word, Excel, and Access
Strong personal and professional ethics
Passion for improving consumer experiences
Must reside in South Carolina
Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) preferred
Understanding of the healthcare industry, claims processing, and investigative process development preferred
Corporate environment and business operations experience preferred
Minimum home internet speed of 25 Mbps download and 10 Mbps upload
Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information

Benefits

Comp & perks

Bonus incentive plan based on company and/or individual performance
Medical, dental, and vision benefits
401(k) retirement savings plan
Paid time off
Company and personal holidays
Paid parental and caregiver leave
Short-term and long-term disability
Life insurance
Dedicated remote workspace requirements to protect member PHI/HIPAA information
Fully remote work in South Carolina
Occasional travel to Humana offices for training or meetings may be required