Sr Investigator

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities, and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable, and equitable. Ready to make a difference? Join us and start doing your life's best work.^SM

The SeniorInvestigator reports directly to the Manager of Investigations. The SeniorInvestigator is responsible for identification, investigation and prevention of healthcare fraud, waste, and abuse. The SeniorInvestigator will utilize claims data, applicable guidelines, and other sources of information to identify aberrant billing practices and patterns. The SeniorInvestigator is responsible to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.

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

Primary Responsibilities:

• Investigate medium to highly complex cases of fraud, waste and abuse
• Detect fraudulent activity by members, providers, employees and other parties against the Company
• Develop and deploy the most effective and efficient investigative strategy for each investigation
• Maintain accurate, current and thorough case information in the Special Investigations Unit's (SIU's) case tracking system
• Collect and secure documentation or evidence and prepare summaries of the findings
• Participate in settlement negotiations and/or produce investigative materials in support of the later
• Communicate effectively, to include written and verbal forms of communication
• Develop goals and objectives, track progress and adapt to changing priorities
• Collect, collate, analyze, and interpret data relating to fraud, waste and abuse referrals
• Ensure compliance of applicable federal/state regulations or contractual obligations
• Report suspected fraud, waste and abuse to appropriate federal or state government regulators
• Comply with goals, policies, procedures and strategic plans as delegated by SIU leadership
• Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at workgroups or regulatory meetings

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:

• Associate's Degree (or higher)
• Active affiliations:
• National Health Care Anti-Fraud Association (NHCAA)
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• Certified Professional Coder (CPC)
• Medical Laboratory Technician (MLT)
• 2 years of equivalent work experience with healthcare related employment
• 2-5 years of experience OR demonstrated intermediate level of knowledge in health care fraud, waste, and abuse (FWA)
• 2-5 years of experience OR demonstrated intermediate level of knowledge in state or federal regulatory FWA requirements
• 2-5 years of experience OR demonstrated intermediate level of knowledge analyzing data to identify fraud, waste and abuse trends
• 2-5 years of experience OR demonstrated intermediate level of proficiency in Microsoft Excel and Word
• Ability to participate in legal proceedings, arbitration, and depositions at the direction of management
• Ability to travel up to 25% of the time within the Southwest region

Preferred Qualifications:

• Intermediate knowledge and experience in any of the following:
• Statistical Analysis Software (SAS)
• R
• Python
• Tableau
• Toad
• Structured Query Language (SQL)
• Visual Basic for Applications (VBA)
• Alteryx
• Intermediate knowledge and experience in any of the following:
• Statistical Analysis
• Regression Analysis
• Linear Analysis
• Market-basket Analysis
• Licensed and/or Certified Pharmacy Technician (CPhT)
• Intermediate knowledge in pharmacy claims processing
• Operational experience with a pharmacy and/or pharmacy benefits manager (PBM)

*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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