Senior 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. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity 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, employee's conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. May request onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. 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.  Where applicable, testimony regarding the investigation may be required in a court of law. May also complete root cause analysis.

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

Primary 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 clinical coding consultant to apply knowledge of coding guidelines to determine validity of aberrances (SIU only)

• Gather all relevant facts to articulate behavior through an Investigation Summary and compliance package.  Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders 

• Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA to ensure additional TIP submission

• Perform member and provider interviews, and review medical documentation as needed 

• Answer inbound calls from members/providers and assist with various inquiries

• Communicate with legal, Law Enforcement, clients and business partners as needed

• Conduct provider onsite audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation

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

• 5+ years of experience in an investigative role working with healthcare claims, managed care and/or within a health insurance environment

• 2+ years of experience working with law enforcement or legal entities or 3-5 years Investigative experience with fraud investigations

• 1+ years of experience with behavioral health codes and service delivery

• Intermediate level of proficiency in MS Excel (ability to use pivot tables, formulas, functions, etc.)

• Intermediate level of proficiency in MS Word (ability to create/edit documents)

Preferred Qualifications

• Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar

• Bachelor’s degree, undergraduate degree in Criminal Justice or related field

• Familiar with CPT code terminology

• Experience with computer research

• Experience with regulatory compliance 

• Experience with data analysis as it relates to financial recovery/settlements

*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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