Job Description
About the position 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 to start Caring. Connecting. Growing together. 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 for conducting investigations which may include field work to perform interviews and obtain records and/or other relevant documentation. Responsibilities • Assess complaints of alleged misconduct received within the company • 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 latter • Communicate effectively, including 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 Requirements • Bachelor's degree OR associate's degree with 3+ years of equivalent work experience and healthcare related employment • 3+ years of experience in healthcare fraud, waste and abuse (FWA) • 2+ years of experience in state or federal regulatory FWA requirements • 2+ years of experience in analyzing data to identify fraud, waste and abuse trends • Intermediate level of proficiency in bolthires Excel and Word • Ability to travel locally (in-state) up to 25% of the time, as needed • Ability to participate in legal proceedings, arbitration and depositions at the direction of management • Access to reliable transportation & valid US driver's license • Reside in the state of Kentucky Nice-to-haves • Demonstrated an intermediate level of knowledge in health care policies, procedures and documentation standards or 2-5 years of experience • Demonstrated intermediate level of skills in developing investigative strategies or 2-5 years of experience • Specialized knowledge/training in healthcare FWA investigations • National Health Care Anti-Fraud Association (NHCAA) • Accredited Health Care Fraud Investigator (AHFI) • Certified Fraud Examiner (CFE) Benefits • Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays • Medical Plan options along with participation in a Health Spending Account or a Health Saving account • Dental, Vision, Life & AD&D Insurance along with Short-term disability and Long-Term Disability coverage • 401(k) Savings Plan, Employee Stock Purchase Plan • Education Reimbursement • Employee Discounts • Employee Assistance Program • Employee Referral Bonus Program • Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.) Apply tot his job