Job Description

Optum, a UnitedHealth Group company, with over 125,000 employees globally, specializes in tackling the biggest challenges in health care by partnering across the entire system. Together, we are transforming health care for a better future for everyone we serve. Here's a statistic that will stop you cold: our country will spend more than $8 trillion on health care in 2020. With that kind of money at play, you can be sure some individuals will figure out a way to get a piece of it illegally. Now, that doesn't even take into account the millions of lives that are held in the balance as well. This is fraud on a scale you couldn't begin to imagine. As a Senior Investigator, you will play a part in putting a stop to it. It's critical work that you will want to be a part of, and we're a place like no other and where you'll do your life's best work.(sm)

Our Senior Investigators work on elite Avoidance Investigations Units (AIUs), dedicated to identifying, investigating and eradicated healthcare fraud. The challenge for you will be the high volume of cases on your plate at one time. You will be part of a team responsible for investigating and resolving instances of healthcare fraud and/or abusive conduct. You will spend your time conducting investigations and putting together your findings.

Part of our screening and selection process involves completing a HireVue video interview and a pre-interview questionnaire for consideration.

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

Primary Responsibilities:

* Triaging, investigating and resolving instances of healthcare fraud, waste, and / or abusive conduct by the medical profession, insured members or the broker community
* Review claims data and conduct analysis to look for patterns of potential fraud, waste and/or abuse
* Utilizing information from claims data analysis, plan members, and other sources to conduct confidential investigations, document relevant findings and report any illegal activities in accordance with all laws and regulations
* Conduct investigations to review claim and case history and compare medical documentation against procedural codes billed
* Using statistically random sampling, interact with medical providers to request medical records for investigations
* Conduct onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation
* Conduct in-person or telephonic interviews of members, providers, and/or additional contacts to gather information to support investigation
* Analyze all information gathered from our onsite team to document additional facts related to the investigation
* Gather information pertinent to the case and provide testimonials regarding the investigation
* Support Compliance, Regulatory, Legal, and Law Enforcement on case actions

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:

* Associates Degree or higher in Criminal Justice (or related field) with 2+ years of experience in a position investigating fraud or a High School Diploma/GED with 5+ years of experience working in a Special Investigations Unit or fraud investigations role
* 2+ years of experience in an investigative role working with healthcare claims, managed care and/or within a health insurance environment
* Intermediate proficiency in MS Excel (ability to use pivot tables, formulas, functions, etc.)
* Intermediate proficiency in MS Word (ability to create/edit documents)
* If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking orders

Preferred Qualifications:

* Bachelor's degree, undergraduate degree in the area of Criminal Justice or related field
* 2+ years of experience working with Law Enforcement agencies at the Local, State & Federal level pertaining to healthcare insurance fraud (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy and/or commercial plans)
* Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

Colorado Residents Only: The salary range for Colorado residents is $53,300 to $95,100. Pay is based on several factors including but not limited to education, work experience, certifications, etc. As of the date of this posting, In addition to your salary, UHG offers the following benefits for this position, subject to applicable eligibility requirements: Health, dental, and vision plans; wellness program; flexible spending accounts; paid parking or public transportation costs; 401(k) retirement plan; employee stock purchase plan; life insurance, short-term disability insurance, and long-term disability insurance; business travel accident insurance; Employee Assistance Program; PTO; and employee-paid critical illness and accident insurance.

*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 Key words: FWA, fraud, waste, abuse, investigator, investigation, legal, law, enforcement, police, healthcare, claims, telecommute, remote, work from home