Lead Program Integrity Investigator

Profile

Description

Humana's Lead Program Integrity Investigator will oversee the monitoring and enforcement of the fraud, waste, and abuse (FWA) compliance program to prevent and detect potential FWA activities pursuant to state and federal rules and regulations. This position will act as primary point of contact for OHCA and other agencies such as the Medicaid Fraud Control Unit (MFCU) and coordinate all aspects of FWA activities in Oklahoma to increase Medicaid program transparency and accountability.

The Lead Program Integrity Investigator will have a new team of Program Integrity Investigators to assist in supporting Oklahoma Medicaid's market They will report to the SIU Director and work closely with Humana's Oklahoma Market.

Responsibilities

Essential Functions and Responsibilities

Carry out the provisions of the compliance plan, including FWA policies and procedures.

Investigate unusual incidents and implement corrective action plans.

Assess records and independently refer suspected member fraud, provider fraud, and member abuse cases to the Oklahoma Health Care Authority (OHCA) and other duly authorized enforcement agencies.

Coordinate across all departments to encourage sensible and culturally-competent business standards.

Oversee internal investigations of FWA compliance issues.

Work with the Contract Compliance Officer and Compliance Officer to create and implement tools and initiatives designed to resolve LDH FWA contract compliance issues.

Respond to FWA questions, problems, and concerns from enrollees, providers, and LDH Program Integrity.

Cooperate effectively with federal, state, and local investigative agencies on FWA cases to ensure best outcomes; work closely with internal and external auditors, financial investigators, and claims processing areas.

Adequately staff and manage the program integrity investigator(s) responsible for all FWA detection programs and activities.

Assist in developing FWA education to train staff, providers, and subcontractors.

Attend State Agency meetings.

COME GROW WITH HUMANA! BENEFITS DAY ONE - STELLAR 401K MATCH - PAID TIME OFF

What you need for success! - Required Qualifications

Bachelor's degree in Public Policy, Business, or related field.

Minimum five (5) years of experience in healthcare or risk management.

Minimum three (3) years of supervisory or leadership experience of program integrity investigators.

Minimum two (2) years of experience in healthcare investigations and/or risk management.

Must be located in Oklahoma, within 25 miles of Oklahoma City.

Work at Home Requirements

Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

What you need to be considered a Superstar! - Preferred Qualifications

Master's degree in Law, Business, Healthcare, or related field.

Extensive knowledge and experience working with state administrative codes and regulations, Medicaid, managed care, and insurance laws and regulations.

Extensive knowledge and experience with program integrity.

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com