Senior Fraud Investigator

UnitedHealth Group•Plymouth, MN

1d•Remote

About The Position

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Sr. Investigator is responsible for investigating and resolving instances of healthcare fraud and/or abuse conducted by medical providers. The investigator will need to gather provider information using internal and external intelligence, claims data, and/or the medical community. The employee will conduct confidential investigations, document relevant findings, and report any illegal activities in accordance with all laws and regulations. Investigators may request a provider onsite to gather and analyze all necessary information and documents related to the investigation. Investigations may include participation in telephone calls with providers, members, clients, legal, compliance, and other investigative areas. The role requires knowledge of and adherence to state and federal compliance policies, reimbursement policies, and contract compliance. Where applicable, testimony regarding the investigation may be required in a court of law. This position is self-directed and works with minimal guidance to solve moderately complex problems and develop solutions accordingly. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

Certified Coding Credential
5+ years of experience working in a government, legal, law enforcement, investigations, healthcare, managed care and/or other health insurance investigation capacity
5+ years of experience in a position investigating medical/behavioral health care fraud
3+ years of experience working in a health care Special Investigations Unit (SIU)
3+ years of experience with medical/behavioral health codes and service delivery
3+ years of experience in CPT and HCPCS coding definitions, rules and books
Intermediate level of proficiency with Excel including utilization of pivot tables, formulas, functions, etc
Proven excellent communication skills in communicating complex information via phone or email with a proven ability to document investigative actions, interviews, and other related actions thoroughly and accurately

Nice To Haves

Accredited Healthcare Fraud Investigator (AHFI) credential from NHCAA
Certified Fraud Examiner (CFE) credential from ACFE
5+ years of experience working in the medical/behavioral health investigation field
3+ years previous law enforcement experience conducting criminal investigations
Experience in presenting investigation findings to law enforcement and regulatory agencies
Proven intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy and/or commercial health insurance)
Experience with NPPES, SIRIS, Accurint and Secretary of State sites
Experience with data analysis as it relates to financial recovery / settlements

Responsibilities

Investigate instances of potential healthcare fraud, waste, and/or abuse (FWA)
Conduct telephonic and/or in-person interviews of members, providers, and other related parties to gather information in support of investigations
Review and analyze claims data to identify patterns and indications of potential FWA
Recommend, where appropriate, an onsite provider investigation for claim and/or clinical audits to gather and analyze all necessary information and documents related to the investigation
Consider and synthesize information from claims data analysis, interviews, and other sources to guide confidential investigations, document relevant findings and report any illegal and otherwise suspect activities related to potential FWA in accordance with all laws and relevant regulations and other requirements
Thoroughly document all investigative activities, present case findings to law enforcement and/or regulatory agencies and testify as required
Meet or exceed job and task related requirements, guidelines, turnaround times and SLAs governing each investigation
Support Compliance, Regulatory, Legal, and Law Enforcement in all matters related to the investigation