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Senior Investigator

Company: UnitedHealth Group
Location: San Francisco
Posted on: November 20, 2023

Job Description:

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us and start doing -your life's best work.
The Senior Investigator reports directly to the Manager of Investigations. The Senior Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. The Senior Investigator will utilize claims data, applicable guidelines and other sources of information to identify aberrant billing practices and patterns. The Senior Investigator is responsible to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.
You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. -
Primary Responsibilities:

  • Investigate -medium to 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
  • Communicate effectively, to include written and verbal forms of communication
  • Develop goals and objectives, track progress and adapt to changing priorities
  • 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 Qualifications: -

    • Bachelor's degree or Associates degree with 2+ years of equivalent related healthcare/work experience -
    • Demonstrated intermediate level of knowledge in health care fraud, waste and abuse (FWA) or 2-5 years of experience
    • Demonstrated intermediate level of knowledge in state or federal regulatory FWA requirements or 2-5 years of experience
    • Demonstrated level of knowledge analyzing data to identify fraud, waste and abuse trends or 2-5 years of experience
    • Ability to travel up to 25% of the time.
    • Must participate in legal proceedings, arbitration, and depositions at the direction of management
    • Demonstrated level of proficiency in Microsoft Excel and Word or 2-5 years of experience

      Preferred Qualifications:

      • Demonstrated intermediate level of knowledge in health care policies, procedures, and documentation standards or 2-5 years of experience
      • Demonstrated intermediate level of skills in developing investigative strategies or 2-5 years of experience
      • 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)

          • Certified Professional Coder (CPC)
          • Medical Laboratory Technician (MLT)

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

            California, Colorado, Nevada, -Connecticut, -New York, New Jersey, -Rhode Island or -Washington Residents Only: -The salary range for -California, Colorado, Nevada, -Connecticut, -New York, New Jersey, -Rhode Island or -Washington -residents is $56,300 to $110,400 -per year. -Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives. -

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

Keywords: UnitedHealth Group, San Francisco , Senior Investigator, Other , San Francisco, California

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