Job Description

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

There's no sugar coating it fraud is rampant in health care. And with a projected total spend at nearly $3 trillion, the stakes couldn't be higher. But it's not just the financial losses that we're worried about. We're in the business of making the health care system work better for everyone, so the abuse impacts millions of lives too. As a Lead Investigator, you'll review claims, look for patterns of potential fraud, waste and/or abuse and interact with medical providers to complete investigations. You'll be fully invested in the outcomes and will be helping the health system work better for everyone with the support and resources of a Fortune 6 industry leader.

The Principal Investigator reports directly to the Manager of Investigations. The Principal Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. The Principal Investigator will utilize claims data, applicable guidelines and other sources of information to identify aberrant billing practices and patterns. The Principal Investigator is responsible to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.

Responsibilities and Duties:

Under the direction of the SIU Manager, the Investigations Consultant will:

Investigate 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 later.

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 work-groups or regulatory meetings.

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 Knowledge, Skills and Abilities:

Bachelor's degree or Associates degree plus two years of equivalent work experience with healthcare related employment

Advanced level of proficiency in Microsoft Excel and Word

Advanced level of knowledge with local, state/federal laws and regulations pertaining to healthcare fraud, waste and abuse (FWA)

Up to 25 % travel

Preferred Qualifications:

Specialized knowledge/training in healthcare FWA investigations

Active affiliations:

National Health Care Anti-Fraud Association (NHCAA)

Accredited Health Care Fraud Investigator (AHFI)

Certified Fraud Examiner (CFE)

License and/or Certified Pharmacy Technician (CPhT)

Basic knowledge in pharmacy claims processing

Operational experience with a pharmacy and/or pharmacy benefits manager (PBM).

Every day, we work to make communities healthier. It's the promise that is at the core of who we are. And our employees' expertise makes all the difference in achieving our goal. Join our elite team today and start doing your life's best work.SM

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better

Every day, we work to make communities healthier. It's the promise that is at the core of who we are. And our employees' expertise makes all the difference in achieving our goal. Join our elite team today and start doing your life's best work.(sm)

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 7 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm)

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

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

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

Job Keywords: Principal Investigator, NJ, New Jersey, Telecommute, PBM, Pharmacy, Medicare, Medicaid, Investigations, Investigator, FWA, Compliance, SIU, Telecommute, Telecommuting, Telecommuter, Work From Home, Remote, Iselin, New Jersey, NJ