Manager, Fraud & Waste (Licensed RN) (Remote US)

DescriptionHumana’s Claims Cost Management (CCM) organization is seeking a Manager, Fraud & Waste to join the Provider Payment Integrity-Clinical Audit team working remote anywhere in the US.

As the Fraud & Waste Manager at Humana, you will support our efforts for ensuring claims payment accuracy, so that our members receive quality healthcare at an affordable price.

You will lead a team of professionals skilled in conducting prepayment and post payment reviews to detect, prevent, and correct fraud, waste, and abuse.Responsibilitiesthat are identified during review.

The ideal candidate for this role is a registered nurse with prior auditing experience, proven leadership ability, and experience in managing multiple and competing priorities.Core Responsibilities* Lead a team of 15 FTEs in the day to day work of reviewing claims payments for clinical/coding accuracy* Assist with reporting clinical findings and recommendations* Identify and suggest process improvement opportunities* Develop and monitor team goals, provide ongoing feedback and coaching, and conduct annual performance reviews* Facilitate cross collaboration with internal resources to promote team work and empowerment to make informed decisionsRequired Qualifications* Bachelor’s Degree in health or business related field or equivalent years of experience in a similar role will be accepted in lieu of a degree* Active Registered Nurse (RN) license* 3+ years of healthcare experience within a fraud investigations or auditing role* 2+ years of direct/indirect leadership and/or progressive business consulting experience* Prior experience with medical coding as well as solid knowledge of healthcare payment methodologies* Prior experience leading meetings and presenting material to broad audiencesWork 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 10×1 (10mbs download x 1mbs upload) is required* A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA informationPreferred Qualifications* Certified Professional Coder (CPC) strongly preferred* Familiarity with CMS and Humana regulatory policies* Prior health insurance claims experience* Prior experience managing Financial Recovery* Prior experience working within a fast paced, metric driven operational setting* Claims inventory managementScheduled Weekly Hours40Colorado Pay RangeThe compensation range represents a good-faith estimate of annualized starting pay at the time of posting based on a full-time 40-hour workweek and may vary based on geographic location and/or employment type.

Individual pay decisions will vary based on demonstrated job-related skills such as education, experience, certifications, etc.82,500-113,475Pay TypeSalaryIncentiveThis job is eligible for a bonus incentive plan.

This incentive opportunity is based upon company and/or individual performance.Description of BenefitsHumana, 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.

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