Senior Investigator
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. If reside in Tennessee, you will have the flexibility to work remotely as you take on some tough challenges.
Requirements
- High School Diploma/GED
- 5+ years of experience working in a FWA / SIU or Fraud investigations role for Tennessee location
- 2+ years of experience within the health insurance claims industry
- 2+ years of experience working with law enforcement or legal entities or 3+ years of Investigative experience with fraud investigations
- 1+ years of knowledge and/or experience with behavioral health codes and service delivery
- Intermediate level of proficiency in Microsoft Excel (pivot tables and macros) and Word (documents)
- Ability to travel 25% of the time in the state of Tennessee for client on-site visits
- Reside in the state of Tennessee
Nice To Haves
- Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
- Experience with computer research
- Experience with regulatory compliance
- Experience with data analysis as it relates to financial recovery/settlements
- Familiar with CPT code terminology
Responsibilities
- Gather and analyze data and information gathered to determine behavior and understand provider/scheme at issue
- Utilize appropriate documentation and tracking controls in the case tracking system to ensure compliance and auditability requirements are met
- Collaborate with clinical coding consultant to apply knowledge of coding guidelines to determine validity of aberrances (SIU only)
- Gather all relevant facts to articulate behavior through an Investigation Summary and compliance package. Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders
- Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA to ensure additional TIP submission
- Perform member and provider interviews, and review medical documentation as needed
- Communicate with legal, Law Enforcement, clients and business partners as needed
Benefits
- comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
