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The Medical/Financial Risk Evaluation Professional II is responsible for supporting the development, implementation and monitoring of medical/financial risk. The Medical/Financial Risk Evaluation Professional II work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

The Medical/Financial Risk Evaluation Professional II in the Fraud Research Analytics Concepts (FRAC) Department works independently to identify potential fraud in the areas of pharmacy, medical, and dental. This individual identifies, assesses, and mitigates any medical or financial risk that arises from inadequate or failed processes, people, systems, or external events. This individual maintains a balance between risk mitigation and efficiency. This person understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. This person makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. This person follows established guidelines/procedures.

FRAC Day to Day:

Fraud Concepts Life-Cycle:

Fraud Concepts are either identified by the individual associate or they come to FRAC from various channels such as: Brainstorming Sessions, Conferences, or other Humana Departments. These concepts go through a life-cycle that can result in a referral to another area for deeper investigation (i.e. SIU [Special Investigations Unit])

Pulling Data

FRAC associates analyze and vet data to identify areas of potential fraud. This data is either pulled by the associate or that associate can send a request to our Data Team to pull more complex or robust datasets.

Research

FRAC associates perform a considerable amount of research to identify potential fraud.

Vet Data

Associates spend a significant amount of time examining their data to identify potential fraud. This process is fluid and often involves pulling additional and/or more specific data to clarify their specific fraud angle.

Refer Verified Fraud Concepts to appropriate area of business

Once the FRAC associate has acquired the necessary information to show potential fraud, then they will organize their findings in a way that is understandable to their audience and send their concept to SIU (Special Investigations Unit) for further pursuit.

Use your skills to make an impact

Required Qualifications

• Minimum 1 year of experience with Humana or other healthcare claims systems
• Ability to do extensive research on a given topic
• Microsoft Excel skills (including sorting/filtering data and utilizing pivot tables)
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Work-At-Home Requirements

• At minimum, a download speed of 25 mbps and an upload speed of 10 mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

• Experience in pulling data with SQL
• Experience using the following systems: PowerBI, PL-SQL, Tableau

Additional Information

• As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called Modern Hire. Modern Hire Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.
• If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews. This is a remote role - #LI-Remote

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 decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$57,700 - $79,500 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.

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 because he or she is a protected veteran. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.