Combine two of the fastest - growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making Healthcare data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life’s best work.
It is Optum’s mission and intent to protect members, providers, business partners, employees and stakeholders by administering a strong 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 strong and balanced review process to ensure industry standards regarding documentation and billing of services are met.
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.
You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
We offer 3 weeks of paid training. The hours during training will be 8:00am to 5:00pm Monday-Friday. Training will be conducted virtually from your home.
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
- 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.
- 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
- Communicate with legal, Law Enforcement, clients and business partners as needed
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.
- High School Diploma / GED (or higher) OR equivalent work experience
- Associate's Degree in the area of Criminal Justice or experience in a related field or 5+ years of experience working in a FWA / SIU or Fraud investigations role
- 2+ years of experience within the health insurance claims industry
- 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 medical/behavioral health codes and service delivery
- Intermediate proficiency in Microsoft Excel (pivot tables and macros) and Microsoft Word (creating, editing, and saving documents)
- Certified Professional Coder (CPC)
- 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
- 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
UnitedHealth Group is an essential business. The health and safety of our team members is our highest priority, so we are taking a science driven approach to slowly welcome and transition some of our workforce back to the office with many safety protocols in place. We continue to monitor and assess before we confirm the return of each wave, paying specific attention to geography-specific trends. At this time, 90% of our non-clinical workforce transitioned to a work at home (remote) status. We have taken steps to ensure the safety of our 325,000 team members and their families, providing them with resources and support as they continue to serve the members, patients and customers who depend on us.
You can learn more about all we are doing to fight COVID-19 and support impacted communities at: https://www.unitedhealthgroup.com/newsroom/addressing-covid.html
Careers with OptumInsight. Information and technology have amazing power to transform the Healthcare industry and improve people's lives. This is where it's happening. This is where you'll help solve the problems that have never been solved. We're freeing information so it can be used safely and securely wherever it's needed. We're creating the very best ideas that can most easily be put into action to help our clients improve the quality of care and lower costs for millions. This is where the best and the brightest work together to make positive change a reality. This is the place to do your life’s best work.SM
Colorado Residents Only: The hourly range for Colorado residents is $25.63 to $45.72. 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.
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.
Keywords: Optum, Healthcare, Recovery, Resolutions, US Telecommute, Clinical, Collections, RN, LVN / LPN, medical coding, work at home, work from home, WAH, WFH, remote, telecommute, hiring immediately, #rpo