Medical Fraud Evaluation Professional

Humana Inc.

Job Overview

Location

Remote Nationwide

Job Type

Full-time

Full Job Description

📋 Description

• The Medical Fraud Evaluation Professional role is critical to ensuring compliance with Humana’s documented standards and procedures regarding fraud and abuse investigations, directly supporting early fraud detection capabilities and regulatory adherence.
• This position plays a key role in partnering with the Special Investigations Unit (SIU) and Risk Adjustment Integrity Unit (RAIU) to document case investigative activities, evidence, and findings to prove or disprove fraud and abuse allegations.
• Day-to-day responsibilities include analyzing medical and financial risk data using Humana’s claims systems (CAS and MTV), interpreting complex claims data, and applying medical claims terminology to identify potential fraud patterns.
• The role requires independent judgment and determination in evaluating risk, preparing detailed reports, and supporting investigations with data-driven insights using tools like Power BI and advanced Excel functions.
• Professionals in this role will routinely use Pivot Tables in Excel for data summarization, trend analysis, and reporting, while leveraging Power BI to visualize trends and support fraud detection initiatives.
• Collaboration with SIU and RAIU teams involves providing analytical support, maintaining accurate records of investigative activities, and ensuring all work aligns with HIPAA compliance and data privacy standards.
• The role contributes to Humana’s mission of improving health outcomes by safeguarding the integrity of healthcare services and protecting member resources from fraudulent activity.
• Working remotely nationwide, the position requires a dedicated, interruption-free workspace to protect member PHI and maintain HIPAA compliance during all data handling and analysis tasks.
• Employees will have the opportunity to deepen expertise in healthcare fraud analytics, gain proficiency in industry-standard tools like Power BI and SQL/Python (preferred), and develop a strong understanding of medical claims processing and risk adjustment integrity.
• Over time, individuals can build a career path in healthcare compliance, fraud investigation, or data analytics within Humana’s growing Fraud Research and Analytics Department.

🎯 Requirements

• Minimum 2 years of Humana claims systems experience specifically with CAS and MTV, along with a solid understanding of medical claims terminology
• Proven experience in data analytics, including hands-on use of Power BI for data visualization and reporting
• Expert-level proficiency in Microsoft Excel, particularly advanced skills in using Pivot Tables for data summarization, analysis, and reporting

🏖️ Benefits

• Competitive annual salary range of $65,000 to $88,600, eligible for bonus incentives based on company and individual performance
• Comprehensive benefits package including medical, dental, and vision coverage, 401(k) retirement savings plan, and life insurance
• Generous time off policies covering paid time off, company and personal holidays, volunteer time off, and paid parental and caregiver leave
• Support for remote work including bi-weekly internet stipends for eligible states (CA, IL, MT, SD) and provision of necessary telephone equipment
• Access to professional development tools and processes such as HireVue for streamlined, flexible interview experiences during hiring

Skills & Technologies

Python

Remote

$65k-88k

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Humana Inc.

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About Humana Inc.

Humana Inc. is a for-profit health and well-being company headquartered in Louisville, Kentucky. Founded in 1961, it provides health insurance, Medicare Advantage plans, Medicaid services, pharmacy benefit management, and clinical care through primary care centers. Serving millions of members across the United States, Humana focuses on integrated care delivery, home health, and wellness programs aimed at improving health outcomes and reducing costs for individuals, employers, and government partners.

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