Investigator

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. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life’s best work.^SM

The Sr. Investigator is responsible for investigating and resolving instances of healthcare fraud, waste and/or abuse (FWA) perpetrated by medical providers and members. Sources such as internal personnel and data assets, claims data, internet resources, government agencies, industry intelligence sharing resources and other sources of information will be utilized in the performance of confidential investigations. These investigations must be and 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 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 or other proceeding such as a civil deposition. This position is self-directed and works with minimal guidance to solve moderately to complex problems and develop solutions accordingly. 

Part of our screening and selection process involves completing a HireVue video interview and a pre-interview questionnaire for consideration. 

If you reside in Nebraska, you will enjoy the flexibility to telecommute* as you take on some tough challenges.

Primary 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
• Conduct onsite provider investigations for claim and/or clinical audits as appropriate 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, turn around times and SLAs governing each investigation
• Support Compliance, Regulatory, Legal, and Law Enforcement in all matters related to the investigation
• Prepare and present case facts and investigations to Legal, Client leadership and state regulators in face-to-face

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• High School Diploma/GED (or higher)
• 2 years working in a health care payer SIU OR 3 years of experience working in a government, legal, law enforcement, investigations, healthcare, behavioral health, behavioral healthcare claims, managed care and/or other health insurance investigation capacity
• 2 years of experience in a position investigating behavioral health fraud
• 2 years of investigative experience with the ability to accurately document investigative actions, interviews and other related actions
• 1 years of experience in conducting computer/internet investigations
• Intermediate level of proficiency with CPT and HCPCS coding definitions, rules, and books, including behavioral health codes and service delivery
• Intermediate level of proficiency with Excel including utilization of pivot tables, formulas, functions, etc.

Preferred Qualifications:

• 3 years previous law enforcement experience conducting criminal investigations
• 5 years of experience working in the behavioral health investigation field
• Undergraduate degree in the field of criminal justice, health care management/delivery, law, or related field
• Accredited Healthcare Fraud Investigator (AHIF) credential from NHCAA
• Certified Fraud Examiner (CFE) credential from ACFE
• Certified Coding credential
• Experience communicating complex information via phone conversations and emails to non-technical clients, providers, internal customers, outside law enforcement agencies and executives
• Experience in presenting investigation findings to law enforcement and regulatory agencies
• An 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)
• ISET and/or Provider Profiler experience
• Experience with NPPES, SIRIS, Accurint and Secretary of State sites
• Experience with data analysis as it relates to financial recovery / settlements 

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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