Senior Investigator - Office Based - Louisville, KY Louisville, KY

    UnitedHealth Group Inc.
    Louisville, KY 40201
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    Job Description

    Our customer service & claims teams are helping people from around the world. We can bring out your best as you put your listening, analytical and problem solving skills to work in a setting that is geared to helping improve lives and enhance health care for millions. Here, you'll discover a wealth of pathways for professional growth within Customer Service and across our global economy. Join us and find out why this the place to do your life's best work.SM

    UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

    The Senior Investigator reports directly to the Manager of Investigations. The Senior Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. The Senior Investigator will utilize claims data, applicable guidelines and other sources of information to identify aberrant billing practices and patterns. The Senior Investigator is responsible to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.

    Primary Responsibilities:
    • Investigate medium to highly complex cases of fraud, waste and abuse
    • Detect fraudulent activity by members, providers, employees and other parties against the Company
    • Develop and deploy the most effective and efficient investigative strategy for each investigation
    • Maintain accurate, current and thorough case information in the Special Investigations Unit's (SIU's) case tracking system
    • Collect and secure documentation or evidence and prepare summaries of the findings
    • Participate in settlement negotiations and/or produce investigative materials in support of the later
    • Collect, collate, analyze and interpret data relating to fraud, waste and abuse referrals
    • Ensure compliance of applicable federal/state regulations or contractual obligations
    • Report suspected fraud, waste and abuse to appropriate federal or state government regulators
    • Comply with goals, policies, procedures and strategic plans as delegated by SIU leadership
    • Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at workgroups or regulatory meetings
    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.

    Required Qualifications:
    • Bachelor's degree or Associate degree plus 3 years of equivalent work experience with healthcare related employment
    • Intermediate knowledge and experience in health care fraud, waste and abuse (FWA) investigations
    • Intermediate knowledge and experience in state and federal regulatory FWA requirements
    • Average skills in data manipulation
    • Average skills in developing investigative strategies
    • Demonstrated ability to communicate effectively, to include written and verbal forms of communication
    • General knowledge of medical benefits, specialty benefits and pharmacy benefits
    • General knowledge of Compliance Program policies, procedures and documentation standards
    • Ability to travel
    • Ability to participate in legal proceedings, arbitrations, depositions, etc.
    • Ability to develop goals and objectives, track progress and adapt to changing priorities
    • Intermediate level of proficiency in Microsoft Excel and Word
    • Intermediate level of knowledge with local, state/federal laws and regulations pertaining to healthcare fraud, waste and abuse (FWA)
    • Must live within the vicinity of Louisville, KY and be willing and able to work full time out of the office
    • Willing and able to travel up to 50% of the time within the state of KY
    • 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
    Preferred Qualifications:
    • Specialized knowledge/training in healthcare FWA investigations
    • Active affiliations:
    - National Health Care Anti-Fraud Association (NHCAA)
    • Accredited Health Care Fraud Investigator (AHFI)
    • Certified Fraud Examiner (CFE)
    Medical - If applicable
    • Certified Professional Coder (CPC)
    • Medical Laboratory Technician (MLT)
    Pharmacy - If applicable
    • License and/or Certified Pharmacy Technician (CPhT)
    • Intermediate knowledge in pharmacy claims processing
    • Operational experience with a pharmacy and/or pharmacy benefits manager (PBM)
    Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 7 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can 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.

    Job Keywords: Senior Investigator, FWA, Investigations, Healthcare, CPC, CFE, AHFI, NHCAA, Travel, Louisville, KY, Kentucky

    Posting ID: 588102396Posted: 2020-11-19