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. It is Optum's mission and intent to protect members, providers, business partners, employees and stakeholders by administering a strong and effective anti-FWAE program designed to prevent, detect, investigate and resolve incidents of potential FWAE, with a focus on education and prevention. Our Company is committed to addressing and correcting known offenses, recovering lost funds, improving overall anti-FWAE ability and partnering with state and federal agencies. Optum supports this commitment to protecting members, providers and other healthcare stakeholders through technologically advanced tools and the administration of a strong and balanced review process to ensure industry standards regarding documentation and billing of services are met. Optum has the Behavioral Health Program and Network Integrity (PNI) team within our organization. This team works with Providers to identify billing as well as payment patterns and trends which may require education or modification of practices or processes on the part of the Provider or Optum. Together with Providers, Optum is committed to identifying and remediating potential Fraud, Waste, Abuse and Error and Payment Integrity Issues. 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.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Job Type
Full-time
Career Level
Entry Level
Industry
Insurance Carriers and Related Activities
Education Level
Bachelor's degree