Senior Fraud Investigator

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together. 

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:  (Percentage shows approximate portion of the working time spent on that responsibility)

• Gather all relevant facts to drive investigations (30%25) 
• Utilize appropriate systems to monitor and document status of investigation (30%25) 
• Collaborate with clinical coding consultants and SMES to determine the validity of aberrances (10%25) 
• Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA to ensure additional TIP submission (5%25) 
• Perform member and provider interviews, and review medical documentation as needed (10%25) 
• Communicate clear rationale for investigation processes and outcome with legal, clients and stakeholders as needed (5%25) 
• Recommend next steps for each case (10%25)  

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 
• 2+ years of experience working with law enforcement or legal entities with fraud or healthcare investigations
• Demonstrated intermediate proficiency in Microsoft Excel (pivot tables and macros) and Word (documents)  

Preferred Qualifications: 

• Healthcare fraud experience
• Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar credentials 
• Familiar with CPT code terminology 
• Experience with computer research 
• Experience with data analysis and manipulating data for analysis 
• Experience in conducting interviews 
• Experience in investigating fraud in behavioral health, durable medical equipment, laboratory or interoperative neuromonitoring cases  
• Experience in conducting case presentations 

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

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable. 

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. 

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

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

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