Senior 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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. Employees are responsible for triaging, investigating and resolving potential instances of healthcare fraud and/or abusive conduct by medical professionals or providers. Using information from tips, complaints, external intelligence or behavior data, 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 request 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. These investigations may include participation in telephone calls or meetings with providers, members, clients, legal, compliance, and other investigative areas and requires 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. May also complete root cause analysis. You’ll enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.

Requirements

5+ years of experience in an investigative role working with healthcare claims, managed care and/or within a health insurance environment
2+ years of experience working with law enforcement or legal entities or 3-5 years Investigative experience with fraud investigations
1+ years of experience with behavioral health codes and service delivery
Intermediate level of proficiency in MS Excel (ability to use pivot tables, formulas, functions, etc.)
Intermediate level of proficiency in MS Word (ability to create/edit documents)

Nice To Haves

Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
Bachelor’s degree, undergraduate degree in Criminal Justice or related field
Familiar with CPT code terminology
Experience with computer research
Experience with regulatory compliance
Experience with data analysis as it relates to financial recovery/settlements

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
Answer inbound calls from members/providers and assist with various inquiries
Communicate with legal, Law Enforcement, clients and business partners as needed
Conduct provider onsite audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation