Program Integrity Researcher

Become a part of our caring community
 

The Program Integrity Researcher is responsible for reviewing, documenting, and researching incoming allegations, referrals, and requests related to potential fraud, waste, and abuse. This role supports program integrity operations by creating and maintaining accurate database records, gathering relevant information through follow-up outreach, and obtaining supporting documentation such as medical records and claims data. The position requires strong attention to detail, organizational skills, and the ability to handle sensitive information professionally and confidentially.

Our Government Contract Requires US Citizenship for this Position

KEY ACCOUNTABILITIES

40% - Review incoming referrals and documentation to ensure all relevant details are captured in the case management system.

40% - Conduct follow-up calls to members, providers, internal partners, or other involved parties to verify information and gather additional details needed for research or case development

20% - Request and track medical records needed to support program integrity reviews and investigations. Request, obtain, and organize claims data for analysis and review. Support analysts, investigators, and leadership by preparing case information and documentation for further review

Use your skills to make an impact
 

Required Qualifications

• High School Diploma
• Basic Computer Knowledge
• Experience Conducting Telephone Outreach and Follow-up Conversations
• Strong Data Entry and Documentation Skills with High Attention to Detail
• Ability to Manage Multiple Assignments and Prioritize
• Organizational and Time Management

Preferred Qualifications

• Basic Medical Claims Experience
• Experience Working with Healthcare Documentation and Databases
• Experience in Program Integrity, Healthcare, Claims Review

Additional Information

Communication

Effectively conveys information in a clear, concise, and professional manner, both verbally and in writing. Listens actively, shares relevant information with appropriate audiences, and adjusts messaging to meet the needs of different stakeholders. Builds understanding and supports collaboration through open and respectful communication.

Attention to Detail

Demonstrates accuracy and thoroughness in completing work. Carefully reviews information, identifies inconsistencies or errors, and ensures tasks, documentation, and processes are completed correctly and completely. Maintains a high standard of quality while following established requirements and procedures.

Critical Thinking

Uses logic, analysis, and sound judgment to evaluate information, solve problems, and make decisions. Identifies root causes, considers risks and alternatives, and applies facts and data to develop effective solutions. Approaches challenges thoughtfully and recommends practical next steps.

Organization

Effectively plans, prioritizes, and manages work to meet deadlines and achieve goals. Maintains orderly records, tracks multiple tasks efficiently, and uses time and resources productively. Demonstrates the ability to coordinate responsibilities in a structured and dependable manner.

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

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.

$53,700 - $72,600 per year

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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us
 

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

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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.