SIU Senior Recovery Resolution Analyst

Healthcare Fraud Investigator

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.

Employees are responsible for triaging, investigating, and resolving potential instances of healthcare fraud and/or abusive conduct by medical professionals or providers. Using information from tips, complaints, external intelligence or behavior data, the medical community and law enforcement, employees conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. Identify, communicate, and recover losses as deemed appropriate. These investigations may include participation in telephone calls or meetings with providers, members, clients, legal compliance, and other investigative areas and requires adherence to state and federal compliance policies, reimbursement policies, and contract compliance.

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Primary Responsibilities:

• Gather and analyze data and information gathered to determine behavior and understand provider/scheme at issue
• Utilize appropriate documentation and tracking controls in the case tracking system to ensure compliance and auditability requirements are met
• Collaborate with SIU Lead Investigator to apply knowledge of coding guidelines to determine validity of aberrances.
• Collaborate with a variety of external sources to identify current and emerging patterns and schemes related to FWA
• Perform member and provider interviews, and review medical documentation as needed
• Communicate with legal, Law Enforcement, clients and business partners as needed
• Perform all other duties as assigned

Required Qualifications:

• High School Diploma/GED
• 5+ years of experience working in a FWA / SIU or Fraud investigations role
• Certified Professional Coder (CPC, CCS, CPMA) or RHIT
• 2+ years of experience within the health insurance claims industry
• 1+ years of knowledge and/or experience with medical/behavioral health codes and service delivery
• Intermediate level of proficiency in Microsoft Excel (pivot tables and macros) and Word (creating, editing, and saving documents)

Preferred Qualifications:

• Associate's degree in Criminal Justice or experience in a related field
• 2+ years of experience working with law enforcement or legal entities or 3+ years of investigative experience with fraud investigations
• Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
• Familiar with CPT code terminology
• Experience with computer research
• Experience with regulatory compliance
• Experience with data analysis as it relates to financial recovery/settlements

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 $24 to $43 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

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.

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.