Senior Investigator - Remote in Nebraska

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

It is Optum's mission and intent to protect members, providers, business partners, employees and stakeholders by administering a solid and effective anti-FWAE program designed to prevent, detect, investigate and resolve incidents of potential FWAE, with a focus on education and prevention. Our Company is committed to addressing and correcting known offenses, recovering lost funds, improving overall anti-FWAE ability and partnering with state and federal agencies. Optum supports this commitment to protecting members, providers and other healthcare stakeholders through technologically advanced tools and the administration of a solid and balanced review process to ensure industry standards regarding documentation and billing of services are met.

Optum has the Behavioral Health Program and Network Integrity (PNI) team within our organization. This team works with Providers to identify billing as well as payment patterns and trends which may require education or modification of practices or processes on the part of the Provider or Optum. Together with Providers, Optum is committed to identifying and remediating potential Fraud, Waste, Abuse and Error and Payment Integrity Issues.

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, employee's conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. May request onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. 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. Where applicable, testimony regarding the investigation may be required in a court of law. May also complete root cause analysis.

If you are located in Nebraska, you will have the flexibility to work remotely* as you take on some tough challenges.

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 clinical coding consultant to apply knowledge of coding guidelines to determine validity of aberrances (SIU only)
• Gather all relevant facts to articulate behavior through an Investigation Summary and compliance package. Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders
• Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA to ensure additional TIP submission
• Perform member and provider interviews, and review medical documentation as needed
• Answer inbound calls from members/providers and assist with various inquiries
• Communicate with legal, Law Enforcement, clients and business partners as needed
• Conduct provider onsite audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation

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:

• 5+ years of experience working in a FWA / SIU or 3 + years fraud investigations experience
• 2+ years of experience in an investigative role working with healthcare claims, managed care and/or within a health insurance environment
• 2+ years of experience working with law enforcement or legal entities or 3+ years of investigative experience with fraud investigations
• 1+ years of knowledge and/or experience with behavioral health codes and service delivery
• Demonstrated intermediate level of proficiency in MS Excel (ability to use pivot tables, formulas, functions, etc.)
• Demonstrated intermediate level of proficiency in MS Word (ability to create/edit documents)
• Reside in Nebraska

Preferred Qualifications:

• Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
• Demonstrated familiarity with CPT code terminology
• Experience with computer research
• Experience with regulatory compliance
• Experience with data analysis as it relates to financial recovery/settlements

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.

The salary range for this role is $59,500 to $116,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.

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.