Investigator

UnitedHealth Group•Warwick, RI

15d•$49,700 - $88,800•Hybrid

About The Position

The Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste, and abuse. The Investigator will utilize claims data, applicable guidelines, and other sources of information to identify aberrant billing practices and patterns. The Investigator is responsible for conducting investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.

Requirements

Associate’s degree or above
Intermediate level of proficiency in Microsoft Excel and Word
Reside within a commutable distance to Warwick, RI
Ability to travel up to 50%, access to reliable transportation, and & valid US driver's license

Nice To Haves

Experience in health care fraud, waste and abuse (FWA) investigations/audit
Experience with state/federal laws and regulations pertaining to healthcare FWA
Experience in analyzing data to identify fraud, waste and abuse trends
Knowledge/training in healthcare FWA investigations
Active affiliations with the National Health Care Anti-Fraud Association (NHCAA)
Accredited Health Care Fraud Investigator (AHFI)
Certified Fraud Examiner (CFE)
Certified Professional Coder (CPC)
Medical Laboratory Technician (MLT)
Statistical Analysis

Responsibilities

Assess complaints of alleged misconduct received within the Company
Investigate low to medium complex cases of fraud, waste, and abuse
Detect fraudulent activity by members, providers, employees, and other parties against the Company
Develop and deploy the most effective and efficient investigative strategy for each investigation
Maintain accurate, current, and thorough case information in the Special Investigations Unit’s (SIU’s) case tracking system
Collect and secure documentation or evidence and prepare summaries of the findings
Participate in settlement negotiations and/or produce investigative materials in support of the latter
Collect, collate, analyze, and interpret data relating to fraud, waste, and abuse referrals
Ensure compliance of applicable federal/state regulations or contractual obligations
Report suspected fraud, waste, and abuse to appropriate federal or state government regulators
Comply with goals, policies, procedures, and strategic plans as delegated by SIU leadership
Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at workgroups or regulatory meetings
Communicate effectively, including written and verbal forms of communication
Develop goals and objectives, track progress and adapt to changing priorities
Must participate in legal proceedings, arbitration, and depositions at the direction of management