SIU Prepay Investigator – US Telecommute

UnitedHealth Group
July 31, 2020
San Antonio, TX
Job Type


Energize your career with one of Healthcare’s fastest growing companies. 

You dream of a great career with a great company – where you can make an impact and help people.  We dream of giving you the opportunity to do just this.  And with the incredible growth of our business, it’s a dream that definitely can come true. Already one of the world’s leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives.  We live for the opportunity to make a difference and right now, we are living it up.
This opportunity is with one of our most exciting business areas: Optum – a growing part of our family of companies that make UnitedHealth Group a Fortune 6 leader.
Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.
The SIU Prepay Investigator – U.S. Telecommute is responsible for triaging, investigating and resolving instances of healthcare fraud and/or abusive conduct by medical professionals. Using information from tips and complaints from plan members, 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 conduct onsite provider claim and / or clinical reviews (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. Identify, communicate and recover losses as deemed appropriate. Where applicable, testimony regarding the investigation may be required. May also complete root cause analysis.

The health care system is still evolving at a rapid pace. Technology is driving new advances in how patient care is delivered and how it's reimbursed. Now, UnitedHealth Group invites you to help us build a more accurate and precise approach to claims adjudication. As part of our Recovery and Resolutions team, you'll help understand and overcome errors in claims processing. You'll have all the tools and backing you need to help manage subrogation files, negotiate settlements and ensure adherence to compliance policies. All the while, you'll be building your career with a leader and reaching for the highest levels of performance as you do your life's best work.

This position is full - time (40 hours / week) required to work core business hours Monday - Friday from 8 am to 4:30 pm local time.

Primary Responsibilities:

  • Initiate phone calls to members, providers, and other insurance companies to gather information
  • Investigate and / or resolve all types of claims for health plans, commercial customers, and government entities
  • Triage claims data to send for medical coding review
  • Collaborate with clinical coding consultants for purposes of educating and communicating to provider
  • Review medical records to gather relevant facts to drive investigations and communications
  • Conduct data mining and analysis for potential flags 
  • Monitor investigation status throughout the process
  • Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA
  • Use pertinent data and facts to identify and solve a range of problems within area of expertise.
  • Generally, work is self - directed and not prescribed
  • Work with less structured, more complex issues
  • Serve as a resource to others
  • Maintain constant awareness of production environment held to Claims per hour (CPH) and QA quality assurance metrics
  • Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders (referrals and OP)
  • Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
  • Utilize appropriate systems to monitor and document status of investigations

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:

  • High School Diploma / GED (or higher)
  • Experience must include one or more of the following:
    • 5 + years of insurance claims investigation experience
    • 5 + years of professional investigation experience with law enforcement agencies
    • 7 + years of professional investigation experience involving economic or insurance related matters
    • Associate’s degree in Criminal Justice (or a related degree) PLUS 2+ years experience with insurance related employment
  • Proficient with Microsoft Excel (sort and filter data) and Microsoft Word (create and edit documents)

Preferred Qualifications:

  • Bachelor’s Degree (or higher) in Criminal Justice (or related degree)
  • Experience using claims platforms such as UNET, Pulse, NICE, Facets, Diamond, etc.  
  • Experience as an authorized medical professional to evaluate medical related claims

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system 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

Diversity creates a healthier atmosphere:UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employerand all qualified applicants will receive consideration for employment withoutregard to race, color, religion, sex, age, national origin, protected veteranstatus, disability status, sexual orientation, gender identity or expression,marital status, genetic information, or any other characteristic protected bylaw.

UnitedHealth Group is a drug - freeworkplace. Candidates are required to pass a drug test before beginningemployment.

Keywords: SIU Investigator, Special Investigation Unit, SIU, Healthcare Investigator, investigation experience, investigator, telecommute, healthcare fraud, healthcare abuse, clinical audits, law enforcement, Criminal Justice

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