SCAN Health Plan jobs

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and healthcare claims to substantiate or refute the accuracy and compliance with federal and state regulations and contractual requirements of codes billed to identify coding errors and billing discrepancies in relation to incidents of suspected healthcare fraud, waste, and abuse (FWA) reported to IEHP's Compliance Special Investigations Unit (SIU). Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary Hybrid schedule State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account - Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities Perform reviews of medical records and healthcare claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations. Understand, interpret, analyze, and make determinations concerning use of CDT, CPT, ICD, DRG, REV and HCPCS coding as it relates to potential healthcare FWA schemes. Conduct research relevant to issues under review. Prepare and submit detailed reports with the results of medical reviews, including corrective action recommendations to investigators. Recommendations may include determinations to deny, recover on overpaid claims, risk mitigation strategies, create internal process improvements or provide education to subjects under review. Apply knowledge of healthcare coding conventions, policies, and other areas of vulnerability. Support/participate in provider calls and reinforce medical review findings and provider education. Presents findings to leadership, regulators and law enforcement and assist in legal proceedings, as appropriate. Maintain knowledge of new and relevant regulations, standards, and coding guidelines. Identify inefficiencies in policies or processes and recommend improvements. Maintain confidentiality and discretion in all investigative activities. Support special projects and other duties as assigned. Qualifications Education & Requirements A minimum of two (2) years of experience performing medical reviews of medical records and claims in a healthcare setting Bachelor's degree in Medical Billing/Medical Coding, Nursing, Healthcare Administration, or related field from an accredited institution required In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position This experience is in addition to the minimum years listed in the Experience Requirements above Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) required One of the following licenses preferred: Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN Key Qualifications Must have a valid California Driver's license Strong understanding of medical coding, billing practices, and healthcare regulations Thorough understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDC's and other guidelines and general understanding of investigative processes within a healthcare environment are required Knowledge of Medi-Cal and Medicare rules and regulations, and managed care in California is preferred Strong verbal and written communication, interpersonal skills, critical problem-solving skills, and attention to detail Above average proficiency in the use of technology applications, particularly Excel, Word, and others as necessary Detail-oriented with strong organizational and time management abilities. Ability to articulate medical review findings clearly and thoroughly Conduct research in support of medical reviews and make determinations on claims with a high level of accuracy Demonstrated ability to interpret and analyze healthcare data and records Adapt to different technology software and platforms, including anti-fraud solutions Ability to work independently and collaboratively with a team Start your journey towards a thriving future with IEHP and apply TODAY! Work Model Location This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA.) Pay Range USD $71,572.80 - USD $93,038.40 /Yr.

CDPHP and its family of companies are mission-driven organizations that support the health and well-being of our customers and the communities we are proud to serve. CDPHP was founded in Albany in 1984 as a physician-guided not-for-profit, and currently offers health plans in 29 counties in New York state. The company values integrity, diversity, and innovation, and its corporate culture supports those values wholeheartedly. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience. CDPHP and its family of companies include subsidiaries Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRX Services, LLC. Strategic Solutions Management Consultants (SSMC) is a full-service medical billing and practice management firm offering a comprehensive, sophisticated approach to private practice physicians, and physician and hospital networks. Strategic Solutions expertise goes beyond traditional transactional billing. Their team of consultants, coders, and billers provide critical insights for their providers. The Medical Biller with SSMC will be responsible for providing direct billing services to their assigned clients, which may include provider offices, hospitals, and other facilities. They will act as a primary resource for billing support, submission of claims, statement management, reporting and other duties as assigned or requested. Billers are required to meet work quality and productivity standards, to ensure outstanding client service. QUALIFICATIONS: High school diploma or GED required Minimum one (1) year of customer service experience required. Experience in a medical office setting strongly preferred. Knowledge of medical billing and/or collections preferred. Experience with Medent preferred. Experience with Microsoft Office, including Outlook, Word and Excel required. Must be detail-oriented with strong organizational skills. Demonstrated ability to pro-actively identify problems, as well as recommend and/or implement effective solutions. Demonstrated ability to provide excellent customer service and develop relationships both internally and externally. Demonstrated ability to work with and maintain confidential information. Excellent verbal and written communication skills. Flexibility to adapt to a changing and fast-paced environment. Please note, the option to work from home is contingent on the below: A dedicated private workspace. Agreement to our telecommuting policy. Wired internet connection and minimum internet speeds. Salary ranges are designed to be competitive with room for professional and financial growth. Individual compensation is based on several factors unique to each candidate, such as work experience, qualifications, and skills. Some roles may also be eligible for overtime pay. Our compensation packages go beyond just salary. In addition to cash compensation, employees have access to award-winning health care coverage, health and flexible spending accounts, and a 401(k) plan with company match. The company also provides a generous paid time off allowance, life insurance, and employee assistance programs. As an Equal Opportunity / Affirmative Action Employer, CDPHP does not discriminate in employment practices on the basis of race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, protected veterans status, or any other characteristics protected under applicable law. To that end, all qualified applicants will receive consideration for employment without regard to any such protected status.

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under the direction of the Supervisor of Product System Configuration, the Analyst II - Product System Configuration is responsible for managing the more complex system configurations within the Business System. The primary functions of this position include but are not limited to, accurate interpretation of state, federal, and contractual guidelines related to benefits, fee schedules, contracts, division of financial responsibility (DOFR), codification of services, and business requirements and translating them into configurable parameters within the Business Systems. The Analyst II - Product System Configuration is independent and acts as a subject matter expert for the business areas by helping to drive decisions related to system configuration. The incumbent will develop and maintain comprehensive documentation of business and technical specification requirements utilizing best practice configuration guidelines developed by the Application Architects within the unit. The Analyst II - Product System Configuration will facilitate communication and formally report findings to various department heads and staff in a manner that is appropriate to the skill level and technical expertise of the audience. This position will be required to train and help educate other team members within the unit as necessary. Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary Telecommute schedule State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account - Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities Assist with the development of configuration standards and best practice guides for maintaining efficiency, accuracy, automation and successful integration with internal and external systems and programs. Analyze and translate business specifications into detailed technical specifications based on system functionality and develop non-systematic workaround processes when necessary. Perform product system error root cause analysis. Track incoming requests and issue resolution through Microsoft Access, MediTrac, and Workfront tools. Identify and communicate impact of system enhancements or configuration changes on integrated systems and processes. Monitor and work daily System Configuration inventory and ensure compliance with established service level agreements and regulatory timelines. Configure and maintain complex product related system builds with multi-tiered functionality and interrelated system dependencies, including but not limited to Contracts, Benefits, Fee Schedules, and Service Categories. Assist Contracting team with drafting appropriate contract fee schedule language to be in line with system adjudication capabilities and coding standards. Develop and maintain business requirements for the automation of coding updates. Track, test, and approve new system functionality, enhancements, and bug fixes, including the development and execution of test plans and scripts. Perform weekly/bi-weekly audit of check run products to proactively identify potential system configuration issues before products are released. Other duties as assigned, including but not limited to Department Projects and LEAN/A3 Events. Qualifications Education & Requirements Four (4) years of experience with the development and remediation of moderately complex system configurations, including capitated provider agreement configurations Experience in major managed care system migration/implementation preferred Bachelor's degree from an accredited institution required In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position: two (2) years of general healthcare experience plus two (2) years of configuration experience is required This experience is in addition to the minimum years listed in the Experience Requirements above Key Qualifications Knowledge of Medicare and Medi-Cal fee schedules and benefit structure, and regulatory billing guidelines required Knowledge of CMS, DHCS, DMHC, NCQA rules and regulations preferred Extensive knowledge of CPT, HCPCS, Revenue, ICD10 coding rules and guidelines preferred Extensive knowledge of general managed care operations required; delegated plan model preferred Basic knowledge of relational database structure Advanced knowledge of Product System algorithms and processes preferred Familiar with basic medical product processing preferred Skilled in the use of Microsoft Excel and Access preferred Exceptional problem solving and critical thinking skills Strong presentation and written communication skills Ability to work independently and solve complex problems with little to no assistance Ability to effectively manage multiple competing priorities Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP's main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership Start your journey towards a thriving future with IEHP and apply TODAY! Work Model Location This position is on a hybrid work schedule. (Monday & Friday - Remote, Tuesday - Thursday onsite in Rancho Cucamonga, CA) Pay Range USD $80,059.20 - USD $106,059.20 /Yr.

The Director of Revenue Integrity serves in a senior leadership capacity and demonstrates client and unit-specific leadership to Revenue Integrity personnel by designing, directing, and executing key Conifer Revenue Integrity processes. This includes Charge Description Master ("CDM") and charge practice initiatives and processes; facilitating revenue management and revenue protection for large, national integrated health systems; regulatory review, reporting and implementation; and projects requiring expertise across multiple hospitals and business units. The Director provides clarity for short/long term objectives, initiative prioritization, and feedback to Managers for individual and professional development of Revenue Integrity resources. The Director leverages project management skills, analytical skills, and time management skills to ensure all requirements are accomplished within established timeframes. Interfaces with highest levels of Client Executive personnel. * Direct Revenue Integrity personnel in evaluating, reviewing, planning, implementing, and reporting various revenue management strategies to ensure CDM integrity. Maintain subject-matter expertise and capability on all clinical and diagnostic service lines related to Conifer revenue cycle operations, claims generation and compliance. * Influence client resources implementing CDM and/or charge practice corrective measures and monitoring tools to safeguard Conifer revenue cycle operations; provide oversight for Revenue Integrity personnel monitoring statistics/key performance indicators to achieve sustainability of changes and compliance with regulatory/non-regulatory directives. * Assume lead role and/or provide direction/oversight for special projects and special studies as required for new client integration, system conversions, new facilities/acquisitions, new departments, new service lines, changes in regulations, legal reviews, hospital mergers, etc. * Serve as primary advisor to and collaboratively with Client/Conifer Senior Executives to ensure requirements are met in the most efficient and cost-effective manner; provides direction to clients for implementation of multiple regulatory requirements. * Serve as mentor and coach for Revenue Integrity personnel and as a resource for manager-level associates. * Maintain a high-level understanding of accounting and general ledger practices as it relates to Revenue Cycle metrics; guide client personnel on establishing charges in appropriate revenue centers to positively affect revenue reporting FINANCIAL RESPONSIBILITY (Specify Revenue/Budget/Expense): Adherence to established/approved annual budget SUPERVISORY RESPONSIBILITIES This position carries out supervisory responsibilities in accordance with guidelines, policies and procedures and applicable laws. Supervisory responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. Direct Reports (incl. titles) : Revenue Integrity Manager/Supervisor Indirect Reports (incl. titles) : Charge Review Specialist I-II, Revenue Integrity Analyst I-III, Charge Audit Specialist To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. * Ability to set direction for large analyst team consistent with Conifer senior leadership vision and approach for executing strategic revenue management solutions * Demonstrated critical-thinking skills with proven ability to make sound decisions * Strong interpersonal communication and presentation skills, effectively presenting information to executives, management, facility groups, and/or individuals * Ability to present ideas effectively in formal and informal situations; conveys thoughts clearly and concisely * Ability to manage multiple projects/initiatives simultaneously, including resourcing * Ability to solve complex issues/inquiries from all levels of personnel independently and in a timely manner * Ability to define problems, collect data, establish facts, draw valid conclusions, and make recommendations for improvement * Advanced ability to work well with people of vastly differing levels, styles, and preferences, respectful of all positions and all levels * Ability to effectively and professionally motivate team members and peers to meet goals * Advanced knowledge of external and internal drivers affecting the entire revenue cycle * Intermediate level skills in MS Office Applications (Excel, Word, Access, Power Point) Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings. EDUCATION / EXPERIENCE Include minimum education, technical training, and/or experience required to perform the job. * Bachelor's degree or higher; seven (7) or more years of related experience may be considered in lieu of degree * Minimum of five years healthcare-related experience required * Extensive experience as Revenue Integrity manager * Extensive knowledge of laws and regulations pertaining to healthcare industry required * Prior healthcare financial experience or related field experience in a hospital/integrated healthcare delivery system required * Consulting experience a plus CERTIFICATES, LICENSES, REGISTRATIONS * Applicable clinical or professional certifications and licenses such as LVN, RN, RT, MT, RPH, CPC-H, CCS highly desirable PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. * While performing the duties of this job, the employee is regularly required to sit for long periods of time; use hands and fingers; reaching with hands and arms; talk and hear. * Must frequently lift and/or move up to 25 pounds * Specific vision abilities required by this job include close vision * Some travel required WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. * Normal corporate office environment TRAVEL * Approximately 10 - 25% Compensation and Benefit Information Compensation Pay: $104,624- $156,957 annually. Compensation depends on location, qualifications, and experience. * Position may be eligible for an Annual Incentive Plan bonus of 10%-25% depending on role level. * Management level positions may be eligible for sign-on and relocation bonuses. Benefits Conifer offers the following benefits, subject to employment status: * Medical, dental, vision, disability, life, and business travel insurance * Management time off (vacation & sick leave) - min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked. * 401k with up to 6% employer match * 10 paid holidays per year * Health savings accounts, healthcare & dependent flexible spending accounts * Employee Assistance program, Employee discount program * Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance. * For Colorado employees, Conifer offers paid leave in accordance with Colorado's Healthy Families and Workplaces Act. Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship. Tenet participates in the E-Verify program. Follow the link below for additional information. E-Verify: ***************************** The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations. **********

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience! Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and healthcare claims to substantiate or refute the accuracy and compliance with federal and state regulations and contractual requirements of codes billed to identify coding errors and billing discrepancies in relation to incidents of suspected healthcare fraud, waste, and abuse (FWA) reported to IEHP's Compliance Special Investigations Unit (SIU). Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. * Competitive salary * Hybrid schedule * State of the art fitness center on-site * Medical Insurance with Dental and Vision * Life, short-term, and long-term disability options * Career advancement opportunities and professional development * Wellness programs that promote a healthy work-life balance * Flexible Spending Account - Health Care/Childcare * CalPERS retirement * 457(b) option with a contribution match * Paid life insurance for employees * Pet care insurance Education & Requirements * A minimum of two (2) years of experience performing medical reviews of medical records and claims in a healthcare setting * Bachelor's degree in Medical Billing/Medical Coding, Nursing, Healthcare Administration, or related field from an accredited institution required * In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position * This experience is in addition to the minimum years listed in the Experience Requirements above * Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) required * One of the following licenses preferred: * Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians * Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN Key Qualifications * Must have a valid California Driver's license * Strong understanding of medical coding, billing practices, and healthcare regulations * Thorough understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDC's and other guidelines and general understanding of investigative processes within a healthcare environment are required * Knowledge of Medi-Cal and Medicare rules and regulations, and managed care in California is preferred * Strong verbal and written communication, interpersonal skills, critical problem-solving skills, and attention to detail * Above average proficiency in the use of technology applications, particularly Excel, Word, and others as necessary * Detail-oriented with strong organizational and time management abilities. Ability to articulate medical review findings clearly and thoroughly * Conduct research in support of medical reviews and make determinations on claims with a high level of accuracy * Demonstrated ability to interpret and analyze healthcare data and records * Adapt to different technology software and platforms, including anti-fraud solutions * Ability to work independently and collaboratively with a team Start your journey towards a thriving future with IEHP and apply TODAY! Pay Range * $71,572.80 USD Annually - $93,038.40 USD Annually

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under the direction of the Supervisor of Product System Configuration, the Analyst II - Product System Configuration is responsible for managing the more complex system configurations within the Business System. The primary functions of this position include but are not limited to, accurate interpretation of state, federal, and contractual guidelines related to benefits, fee schedules, contracts, division of financial responsibility (DOFR), codification of services, and business requirements and translating them into configurable parameters within the Business Systems. The Analyst II - Product System Configuration is independent and acts as a subject matter expert for the business areas by helping to drive decisions related to system configuration. The incumbent will develop and maintain comprehensive documentation of business and technical specification requirements utilizing best practice configuration guidelines developed by the Application Architects within the unit. The Analyst II - Product System Configuration will facilitate communication and formally report findings to various department heads and staff in a manner that is appropriate to the skill level and technical expertise of the audience. This position will be required to train and help educate other team members within the unit as necessary. Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary Telecommute schedule State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account - Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities Assist with the development of configuration standards and best practice guides for maintaining efficiency, accuracy, automation and successful integration with internal and external systems and programs. Analyze and translate business specifications into detailed technical specifications based on system functionality and develop non-systematic workaround processes when necessary. Perform product system error root cause analysis. Track incoming requests and issue resolution through Microsoft Access, MediTrac, and Workfront tools. Identify and communicate impact of system enhancements or configuration changes on integrated systems and processes. Monitor and work daily System Configuration inventory and ensure compliance with established service level agreements and regulatory timelines. Configure and maintain complex product related system builds with multi-tiered functionality and interrelated system dependencies, including but not limited to Contracts, Benefits, Fee Schedules, and Service Categories. Assist Contracting team with drafting appropriate contract fee schedule language to be in line with system adjudication capabilities and coding standards. Develop and maintain business requirements for the automation of coding updates. Track, test, and approve new system functionality, enhancements, and bug fixes, including the development and execution of test plans and scripts. Perform weekly/bi-weekly audit of check run products to proactively identify potential system configuration issues before products are released. Other duties as assigned, including but not limited to Department Projects and LEAN/A3 Events. Qualifications Education & Requirements Four (4) years of experience with the development and remediation of moderately complex system configurations, including capitated provider agreement configurations Experience in major managed care system migration/implementation preferred Bachelor's degree from an accredited institution required In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position: two (2) years of general healthcare experience plus two (2) years of configuration experience is required This experience is in addition to the minimum years listed in the Experience Requirements above Key Qualifications Knowledge of Medicare and Medi-Cal fee schedules and benefit structure, and regulatory billing guidelines required Knowledge of CMS, DHCS, DMHC, NCQA rules and regulations preferred Extensive knowledge of CPT, HCPCS, Revenue, ICD10 coding rules and guidelines preferred Extensive knowledge of general managed care operations required; delegated plan model preferred Basic knowledge of relational database structure Advanced knowledge of Product System algorithms and processes preferred Familiar with basic medical product processing preferred Skilled in the use of Microsoft Excel and Access preferred Exceptional problem solving and critical thinking skills Strong presentation and written communication skills Ability to work independently and solve complex problems with little to no assistance Ability to effectively manage multiple competing priorities Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP's main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership Start your journey towards a thriving future with IEHP and apply TODAY! Work Model Location This position is on a hybrid work schedule. (Monday & Friday - Remote, Tuesday - Thursday onsite in Rancho Cucamonga, CA) Pay Range USD $80,059.20 - USD $106,059.20 /Yr.

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and healthcare claims to substantiate or refute the accuracy and compliance with federal and state regulations and contractual requirements of codes billed to identify coding errors and billing discrepancies in relation to incidents of suspected healthcare fraud, waste, and abuse (FWA) reported to IEHP's Compliance Special Investigations Unit (SIU). Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary Hybrid schedule State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account - Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities Perform reviews of medical records and healthcare claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations. Understand, interpret, analyze, and make determinations concerning use of CDT, CPT, ICD, DRG, REV and HCPCS coding as it relates to potential healthcare FWA schemes. Conduct research relevant to issues under review. Prepare and submit detailed reports with the results of medical reviews, including corrective action recommendations to investigators. Recommendations may include determinations to deny, recover on overpaid claims, risk mitigation strategies, create internal process improvements or provide education to subjects under review. Apply knowledge of healthcare coding conventions, policies, and other areas of vulnerability. Support/participate in provider calls and reinforce medical review findings and provider education. Presents findings to leadership, regulators and law enforcement and assist in legal proceedings, as appropriate. Maintain knowledge of new and relevant regulations, standards, and coding guidelines. Identify inefficiencies in policies or processes and recommend improvements. Maintain confidentiality and discretion in all investigative activities. Support special projects and other duties as assigned. Qualifications Education & Requirements A minimum of two (2) years of experience performing medical reviews of medical records and claims in a healthcare setting Bachelor's degree in Medical Billing/Medical Coding, Nursing, Healthcare Administration, or related field from an accredited institution required In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position This experience is in addition to the minimum years listed in the Experience Requirements above Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) required One of the following licenses preferred: Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN Key Qualifications Must have a valid California Driver's license Strong understanding of medical coding, billing practices, and healthcare regulations Thorough understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDC's and other guidelines and general understanding of investigative processes within a healthcare environment are required Knowledge of Medi-Cal and Medicare rules and regulations, and managed care in California is preferred Strong verbal and written communication, interpersonal skills, critical problem-solving skills, and attention to detail Above average proficiency in the use of technology applications, particularly Excel, Word, and others as necessary Detail-oriented with strong organizational and time management abilities. Ability to articulate medical review findings clearly and thoroughly Conduct research in support of medical reviews and make determinations on claims with a high level of accuracy Demonstrated ability to interpret and analyze healthcare data and records Adapt to different technology software and platforms, including anti-fraud solutions Ability to work independently and collaboratively with a team Start your journey towards a thriving future with IEHP and apply TODAY! Work Model Location This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA.) Pay Range USD $71,572.80 - USD $93,038.40 /Yr.

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************

Become a part of our caring community and help us put health first Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas Use your skills to make an impact WORK STYLE: Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. WORK HOURS: Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones Required Qualifications • Bachelor's degree • 2 years of healthcare fraud investigations and auditing experience • 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, Access • Strong personal and professional ethics • Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications • Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) • Experience testifying in court • Understanding of healthcare industry, claims processing, and investigative process development • Experience in a corporate environment and understanding of business operations Additional Information Work at Home Requirements • 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 How We Value You • Benefits starting day 1 of employment • Competitive 401k match • Generous Paid Time Off accrual • Tuition Reimbursement • Parent Leave • Go365 perks for well-being 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. #ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. 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. $65,000 - $88,600 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: 12-29-2025 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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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.

**Become a part of our caring community and help us put health first** Humana is looking for an experienced Healthcare Investigator to join its industry leading Special Investigations Unit. Do you enjoy speaking with members, providers, and other industry colleagues? Do you thrive on solving problems and thinking outside the box? Are you self-driven and enjoy being proactive? But, most of all do you have a passion for combating Fraud, Waste, and Abuse in the Health Care Industry? If this resonates with you, then you should strongly consider this amazing opportunity to join Humana's SIU. The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Fraud and Waste Investigator collaborates in investigations 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 investigative and audit reports. Begins to influence department's strategy. Makes decisions on issues regarding technical approach for project components. Exercises good judgment with considerable latitude in determining objectives and approaches to assignments. In order to thrive in this role, the following attributes and experience would be helpful: o Self-starter and organized o Interview skills and able to conduct a thorough investigation to maintain compliance with Humana and governmental requirements o Able to collaborate with internal and external partners (Law Enforcement, Legal, Compliance). o Comfort with data analysis (Excel, Access, PowerBI), report writing, and creating/presenting via PPT or other platform o Performing Investigative research and medical record reviews o CPT code experience o Experience with testifying in Court This role will regularly engage with all of the following: o Local, State and Federal Law Enforcement o Humana Legal and Outside Counsel o Internal Compliance o Market Areas o Clinical Teams o Business areas for all product lines (Medicare, Medicaid, Commercial) o Industry Trend areas **Use your skills to make an impact** **WORK STYLE:** Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical work hours are Monday-Friday, 8 hours/day, 5 days/week. EST/CST time zones **Required Qualifications** - Bachelor's degree - 2 years of healthcare fraud investigations and auditing experience - 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, Access - Strong personal and professional ethics - Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** - Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI) - Experience testifying in court - Understanding of healthcare industry, claims processing, and investigative process development - Experience in a corporate environment and understanding of business operations **Additional Information** **Work at Home Requirements** - 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 **How We Value You** - Benefits starting day 1 of employment - Competitive 401k match - Generous Paid Time Off accrual - Tuition Reimbursement - Parent Leave - Go365 perks for well-being **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. \#ThriveTogether #WorkAtHome Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **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. $65,000 - $88,600 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: 12-29-2025 **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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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 ***************************************************************************