Healthcare Claims Investigator - Brentwood, TN

Position Description:
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 14 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, and Performance.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.

Required Qualifications:


Associate's Degree in the area of Criminal Justice or related field OR High School Diploma/GED with 2+ years experience working in fraud investigations
1+ year of experience working in fraud investigations (healthcare fraud experience preferred).
Experience with Microsoft Excel and Microsoft 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, particularly within claims processing
Certified Coding Specialist 
Certified Fraud Examiner 
Experience with law enforcement investigation.
Experience within the insurance claims industry  
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.