566844: *** Behavioral Health Senior Investigator - Tennessee Telecommuter

Health care fraud is a serious problem affecting every patient and consumer. The devastating situation is rooted not only in the excessive financial losses incurred, which extend into the billions of dollars every year, but also in patient harm. According to the National Health Care Antifraud Association (NHCAA), health care fraud, waste and abuse strips nearly $70 billion from the industry each year. The NHCAA estimate represents 3 percent of the $2.26 trillion dollars spent on health care annually in the United States. Since insurance fraud is hard to detect, these figures can only hint at the magnitude of the problem, with some loss estimates ranging as high as 10 percent of health care expenditures, or $230 billion annually. Bring us your experience, your eye for detail, your passion for combating FWA. In return we offer an unmatched place to grow and develop your career at the leading health care organization in the country. Come help us heal and strengthen the health care system as you do your life's best work.(sm)

Optum Behavioral Solutions, part of the UnitedHealth Group family of companies, is looking for an experienced Behavioral Health Senior Investigator to join our dynamic Special Investigations Unit in Tennessee. Things are exciting at UHG as we are experiencing unprecedented growth, and looking for someone with the right stuff for our Special Investigations Unit. The Behavioral Health Senior Investigator is responsible for regulatory compliance processes and audits in order to prevent Fraud, Waste and Abuse (FWA) related to Behavioral Health, Mental Health and/or Substance Abuse. The Sr. Investigator works with internal and external sources to ensure that FWA issues are handled timely and according to applicable laws and regulations. They will triage, investigate and resolve instances of health care fraud, waste and/or abuse. They will meet compliance standards, customer expectations and network need around the education and actual prevention of fraudulent, wasteful and abusive practices. The Sr. Investigator conducts and reviews onsite and desk audits of potential FWA from TN members, providers or other medical professionals, internal and external sources.  They provide investigative support in pursuing recovery of inappropriate and/or insupportable claims in TN. The Sr. Investigator formulates audit reports and identifies and documents funds to be recovered and returned to the company. They proactively pursue the detection and prevention of payment of fraudulent claims in the TN market. NOTE: This position must be based in Tennessee, and is open as a telecommuting / work from home opportunity.

Primary Responsibilities:

• Gather / Analyze Data to Drive or Recommend Further Investigations


• Conduct Investigations and Manage Cases


• Resolve Investigations and Negotiate Settlements


• Document Case Activities and Communicate Outcomes


• Ensure Compliance with Applicable TN and National Laws, Regulations and Guidelines

Required Qualifications:

• Bachelor's degree and/or 3+ years of related work experience


• 2+ years of experience working in Special Investigations Unit (Fraud, Waste & Abuse tracking / monitoring and detection of healthcare claims)


• 2+ years of experience working with State / Federal Regulations related to Fraud & Abuse


• Knowledge of the health care and benefit industry, as well as specific knowledge around standard behavior health coding and billing practices


• Demonstrated advanced knowledge of medical terminology and coding guidelines for CPT, HCPCS, ICD-9, and ICD-10


• Ability to assist / provide guidance on claims analysis (data analysis) to determine and create / manage investigative plans


• Strong verbal & written communication, multitasking & time/project management, analytical & problem solving, and organizational skills required (ability to balance multiple priorities)


• Ability to work under high pressure / timelines / regulatory and business constraints to achieve goals and targets


• Ability to support heavy workload volume and meet unit standards while engaging multiple priorities


• An intermediate or better level of proficiency in MS Excel and MS Word

Preferred Qualifications:

• Knowledge of Behavioral Health, Mental Health and/or Substance Abuse


• Certified Fraud Examiner


• Certification as a professional coder

Optum Behavioral Solutions is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system. At Optum Behavioral Solutions, you will perform within an innovative culture that's focused on transformational change in the health care system. You will leverage your skills across a diverse and multi-faceted business. And you will make contributions that will have an impact that's greater than you've ever imagined.  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: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.

Job Keywords: FWA Investigator, Fraud, Waste, Abuse, Healthcare, Claims, Brentwood, Nashville, TN