Senior Investigator - Telecommute in Ohio and/or Congruent States
UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)
The Senior Investigator reports directly to the Manager of Investigations. The Senior Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. The Senior Investigator will utilize claims data, applicable guidelines and other sources of information to identify aberrant billing practices and patterns. The Senior Investigator is responsible to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.
If you are located in the state of OH or a congruent state to OH, you will have the flexibility to telecommute* as you take on some tough challenges.
- 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
- 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 work-groups 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.
- Bachelor’s degree or Associates degree plus two years of equivalent work experience with healthcare related employment
- Advanced level of proficiency in Microsoft Excel and Word
- Advanced level of knowledge with local, state/federal laws and regulations pertaining to healthcare fraud, waste and abuse (FWA)
- Advanced knowledge and experience in health care fraud, waste and abuse (FWA) investigations
- Advanced knowledge and experience in state and federal regulatory FWA requirements
- Advanced knowledge of medical benefits, specialty benefits and pharmacy benefits
- Advanced knowledge of Compliance Program policies, procedures and documentation standards
- Above average skills in data manipulation
- Excellent skills in developing investigative strategies
- Ability to supervise a team
- Ability to communicate effectively, to include written and verbal forms of communication
- Ability to travel
- Ability to participate in legal proceedings, arbitrations, depositions, etc.
- Ability to develop goals and objectives, track progress and adapt to changing priorities
- Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
- Specialized knowledge/training in healthcare FWA investigations
- Active affiliations:
- National Health Care Anti-Fraud Association (NHCAA)
- Accredited Health Care Fraud Investigator (AHFI)
- Certified Fraud Examiner (CFE)
- Medical - If applicable
- Certified Professional Coder (CPC)
- Medical Laboratory Technician (MLT)
- Pharmacy - If applicable
- License and/or Certified Pharmacy Technician (CPhT)
- Intermediate knowledge in pharmacy claims processing
- Operational experience with a pharmacy and/or pharmacy benefits manager (PBM)
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.
Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 5 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm)
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
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.