Healthcare Claims Investigator - San Juan, PR

UnitedHealth Group•San Juan, PR

2d•Onsite

About The Position

Employees are responsible for triaging, investigating and resolving instances of healthcare fraud and/or abusive conduct by medical professionals. Using information from tips and complaints from plan members, the medical community and law enforcement, employee's conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. May conduct onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. Identify, communicate and recover losses as deemed appropriate. Where applicable, testimony regarding the investigation may be required. May also complete root cause analysis. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Requirements

2+ years of experience in Claims processing
Experience using claims platforms such as UNET, Pulse, NICE, Facets, Diamond, etc.
Working experience with Microsoft Tools: Microsoft Teams (join meetings and trainings), Microsoft Power Point (prepare presentations), Microsoft Word (creating memos, writing), Microsoft Outlook (setting calendar appointments, email) and Microsoft Excel (creating spreadsheets, filtering, navigating reports)
Ability to work (40 hours/week) Monday - Friday. Flexible to work any of our 8-hour shift schedules during our normal business hours of (6:00am to 6:00pm EST). It may be necessary, given the business need, to occasionally work mandatory overtime, holidays or weekends
English proficiency
Driver’s License and access to reliable transportation

Nice To Haves

Organization affiliation and/or certification: Association of Certified Fraud Examiners (ACFE), Certified Fraud Examiner (CFE), National Health Care Anti-Fraud Association (NHCAA), Accredited Healthcare Fraud Investigator (AHFI), International Association of Special Investigation Units (IASIU), Certified Insurance Fraud Investigator (CIFI), Certified Insurance Fraud Analyst (CIFA), Certified Insurance Fraud Representative (CIFR)
1+ yrs of experience in Appeals and Grievances
Provider demographic information
Insurance billing practices
Coding experience
Managed care experience
Claims processing experience
Medical record familiarity
Experience in healthcare claims investigations
Experience in lean and/or six sigma methodology

Responsibilities

Assist the prospective team with special projects and reporting
Initiate phone calls to members, providers, and other insurance companies to gather information
Investigate and/or resolve all types of claims for health plans, commercial customers, and government entities
Triage claims data to send for medical coding review
Collaborate with clinical coding consultants for purposes of educating and communicating to provider
Review medical records to gather relevant facts to drive investigations and communications
Conduct data mining and analysis for potential flags
Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders (referrals and OP)
Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
Utilize appropriate systems to monitor and document status of investigations
Monitor investigation status throughout the process
Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA
Use pertinent data and facts to identify and solve a range of problems within area of expertise
Generally, work is self - directed and not prescribed
Work with less structured, more complex issues
Serve as a resource to others