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Healthcare Claims Investigator - Brentwood, TN
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | Brentwood, TN Brentwood, Tennessee |
About this job
Position Description:
The Investigator will be responsible for investigating and resolving instances of healthcare fraud and/or abusive conduct by the medical profession, insured members or the broker community. This individual will be utilizing information from claims data analysis, plan members, employee's conduct confidential investigations and document relevant findings. They will report any illegal activities in accordance with all laws and regulations. The Investigator may also conduct onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. They will act as a subject matter with identifying, communicating and recovering losses as deemed appropriate. Where applicable, they will provide testimonials regarding the investigation.
The roles in this function are not within claims and underwriting. Employee's are responsible for triaging, investigating and resolving instances of healthcare fraud and/or abusive conduct by the medical profession, insured members or the broker community.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 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.Where applicable, testimony regarding the investigation may be required. May also complete root cause analysis.
- Analyzes and investigates.
- Provides explanations and interpretations within area of expertise.
Requirements
Required Qualifications:
- Associate's degree in the area of Criminal Justice or related field OR HS diploma/GED with 2+ years experience
- 1+ years of experience working in fraud investigations (healthcare fraud experience preferred).
- Proficiency in MS Excel and MS Word (formulas, graphs, pivot tables)
- Knowledge with Local, State & Federal laws and regulations pertaining to insurance required.
Preferred Qualifications:
- Experience with the group health business preferred, particularly within claims processing
- Certified Coding Specialist
- Certified Fraud Examiner
- Experience with law enforcement investigation.
- Experience within the insurance claims industry required.
- Experience with Facets, iDRS, CSP, Macess, or other claims processing systems.
Soft Skills:
- Must be self-motivated, goal oriented and have the ability to work independently to successfully investigate complex issues.
- Strong verbal and written communication, time/project management, problem solving, organizational, and analytical skills required.
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: 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.
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