Audit & Recovery Investigator - Boston, MA - Full-time / Part-time

Position Description:
 
You'll join a high caliber team where you're assisting, educating, problem-solving and resolving tenuous situations to the best possible outcomes. Bring your people skills, emotional strength and attention to detail. In return we offer the latest tools and most intensive training program in the industry. Get ready to start doing your life's best work.(sm)
The Audit & Recovery Investigator will be responsible for triaging, investigating and resolving instances of healthcare fraud and / or wasteful and abusive conduct by health care providers who submit claims for payment. This position will be utilizing information from claims data analysis, plan members, the medical community, law enforcement, employee conduct, and confidential investigations in order to document relevant findings.  The investigator will conduct onsite and desk audits of provider claims and / or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documentation related to the investigation, and prepare all necessary reports. The investigator will input information into Optum audit workflow tools and the client’s case tracking system.  The investigator will act as a subject matter expert in identifying, communicating and recouping improper payments as deemed appropriate. Where applicable, the investigator will provide appeals and investigative support, as well as testimony.  Primary Responsibilities:

Investigate, audit, and resolve all types of Medicaid claims as well as recovery and resolution for government payers
Process recovery on claims
Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
Use pertinent data and facts to identify and solve a range of problems within area of expertise
The successful candidate will be part of a group of auditors deployed to investigate possible fraud, waste and abuse in Massachusetts
Generally work is self-directed and not prescribed
Works with less structured, more complex issues
Serves as a resource to others and as a lead to analyst positions

Requirements:

Associate’s Degree or higher
Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or clinical expertise (RN) or similar
4+ years of experience with auditing and monitoring
Experience with MS Excel including data entry, sorting, creating / modifying spreadsheets, Vlookup, and formulas
Up to 25% travel required
Assets:

Familiarity with CPT-4, HCPCs and ICD-9 / 10 code terminology
Experience with data analysis as it relates to financial recovery / settlements
MS Access (create and modify queries and reports)
Knowledge of Medicaid / Medicare Reimbursement methodologies
Knowledge of claims processing systems (general knowledge in how claims are processed) and guidelines / processes
Experience working with long-term services and supports provided by Medicaid
Experience working with state Medicaid programs
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 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:  UHG, UnitedHealth Group, claims, Recovery Resolutions Consultant, Boston, Massachusetts, Medicaid, Medicare, claims processing, healthcare, customer service