SIU Senior Recovery Resolution Analyst

UnitedHealth Group•Plymouth, MN

5d•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. 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, employees conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. 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. You will enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.

Requirements

High School Diploma/GED and 5+ years of experience working in a FWA / SIU or Fraud investigations role OR Associate’s degree in Criminal Justice or experience in a related field
Certified Professional Coder (CPC)
2+ years of experience within the health insurance claims industry
1+ years of knowledge and/or experience with medical/behavioral health codes and service delivery
Intermediate level of proficiency in Microsoft Excel (pivot tables and macros) and Word (creating, editing, and saving documents)

Nice To Haves

2+ years of experience working with law enforcement or legal entities or 3+ years of investigative experience with fraud investigations
Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
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 SIU Lead Investigator to apply knowledge of coding guidelines to determine validity of aberrances.
Collaborate with a variety of external sources to identify current and emerging patterns and schemes related to FWA
Perform member and provider interviews, and review medical documentation as needed
Communicate with legal, Law Enforcement, clients and business partners as needed
Perform all other duties as assigned