CPS Solutions
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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
The Sr. Investigator is responsible for investigating and resolving instances of healthcare fraud and/or abuse conducted by medical providers. The investigator will need to gather provider information using internal and external intelligence, claims data, and/or the medical community. The employee will conduct confidential investigations, document relevant findings, and report any illegal activities in accordance with all laws and regulations. Investigators may request a provider onsite to gather and analyze all necessary information and documents related to the investigation. Investigations may include participation in telephone calls with providers, members, clients, legal, compliance, and other investigative areas. The role requires knowledge of and 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. This position is self-directed and works with minimal guidance to solve moderately complex problems and develop solutions accordingly.
You’ll enjoy the flexibility to work remotely* from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.
Primary Responsibilities:
Investigate instances of potential healthcare fraud, waste, and/or abuse (FWA)
Conduct telephonic and/or in-person interviews of members, providers, and other related parties to gather information in support of investigations
Review and analyze claims data to identify patterns and indications of potential FWA
Recommend, where appropriate, an onsite provider investigation for claim and/or clinical audits to gather and analyze all necessary information and documents related to the investigation
Consider and synthesize information from claims data analysis, interviews, and other sources to guide confidential investigations, document relevant findings and report any illegal and otherwise suspect activities related to potential FWA in accordance with all laws and relevant regulations and other requirements
Thoroughly document all investigative activities, present case findings to law enforcement and/or regulatory agencies and testify, as required
Meet or exceed job and task related requirements, guidelines, turnaround times and SLAs governing each investigation
Support Compliance, Regulatory, Legal, and Law Enforcement in all matters related to the investigation
Review medical records and triage claims data to send for medical coding review to ensure adherence to PHI policies
Responsible for communications with the provider regarding the provider flagging and lettering process
Collaborate with a variety of external sources to maintain timely review of cases and ensure inventory adheres to required turnaround time expectations
Responsible for monthly reporting to regulators, our clients, and others, as the business need requires
Generally, work is self – directed, requiring minimal direction and not prescribed
Work with less structured, and more complex issues while still following department processes
Serve as a resource to others
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:
2+ years of experience in a position investigating medical/behavioral health care fraud
2+ years working in a health care payer SIU
1+ year experience working with the FACETS platform
Knowledge and/or experience with medical/behavioral health codes and service delivery
Working knowledge of CPT and HCPCS coding definitions, rules and books
Intermediate proficiency with Excel including utilization of pivot tables, formulas, functions, etc.
Excellent communication skills in communicating complex information via phone or email with a proven ability to document investigative actions, interviews, and other related actions thoroughly and accurately
Preferred Qualifications:
Accredited Healthcare Fraud Investigator (AHFI) credential from NHCAA
Certified Fraud Examiner (CFE) credential from ACFE
Certified Coding credential
Experience working in the medical/behavioral health investigation field
Experience in presenting investigation findings to law enforcement and regulatory agencies
Experience with data analysis as it relates to financial recovery / settlements
An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy and/or commercial health insurance)
*All employees working remotely 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 $58,800 to $105,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
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.
CPS Solutions
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