[Hiring] Senior Fraud Investigator @UnitedHealth Group

Role Description

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.

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

Qualifications

• Certified Coding Credential
• 5+ years of experience working in a government, legal, law enforcement, investigations, healthcare, managed care and/or other health insurance investigation capacity
• 5+ years of experience in a position investigating medical/behavioral health care fraud
• 3+ years of experience working in a health care Special Investigations Unit (SIU)
• 3+ years of experience with medical/behavioral health codes and service delivery
• 3+ years of experience in CPT and HCPCS coding definitions, rules and books
• Intermediate level of proficiency with Excel including utilization of pivot tables, formulas, functions, etc

Requirements

• Accredited Healthcare Fraud Investigator (AHFI) credential from NHCAA
• Certified Fraud Examiner (CFE) credential from ACFE
• 5+ years of experience working in the medical/behavioral health investigation field
• 3+ years previous law enforcement experience conducting criminal investigations
• Experience in presenting investigation findings to law enforcement and regulatory agencies
• Proven 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)
• Experience with NPPES, SIRIS, Accurint and Secretary of State sites
• Experience with data analysis as it relates to financial recovery / settlements

Soft Skills

• Proven 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

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)

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.