Sr. Investigator – Telecommute in TN

UnitedHealth Group
July 8, 2021
Atlanta, GA
Job Type


Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

It is Optum’s mission and intent to protect members, providers, business partners, employees and stakeholders by administering a strong and effective anti-FWAE program designed to prevent, detect, investigate and resolve incidents of potential FWAE, with a focus on education and prevention. Our Company is committed to addressing and correcting known offenses, recovering lost funds, improving overall anti-FWAE ability and partnering with state and federal agencies. Optum supports this commitment to protecting members, providers and other healthcare stakeholders through technologically advanced tools and the administration of a strong and balanced review process to ensure industry standards regarding documentation and billing of services are met.

Optum has the Behavioral Health Program and Network Integrity (PNI) team within our organization. This team works with Providers to identify billing as well as payment patterns and trends which may require education or modification of practices or processes on the part of the Provider or Optum. Together with Providers, Optum is committed to identifying and remediating potential Fraud, Waste, Abuse and Error and Payment Integrity Issues.

Employees are responsible for triaging, investigating and resolving potential instances of healthcare fraud and/or abusive conduct by medical professionals or providers. Using information from tips, complaints, external intelligence or behavior data, 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 request 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.  These investigations may include participation in telephone calls or meetings with providers, members, clients, legal, compliance, and other investigative areas and requires adherence to state and federal compliance policies, reimbursement policies, and contract compliance.  Where applicable, testimony regarding the investigation may be required in a court of law. May also complete root cause analysis.

If you are located within the state of Tennessee, you will have the flexibility to telecommute* as you take on some tough challenges. 

Primary Responsibilities: 

  • Gather and analyze data and information gathered to determine behavior and understand provider/scheme at issue 
  • Utilize appropriate documentation and tracking controls in the case tracking system to ensure compliance and auditability requirements are met 
  • Collaborate with clinical coding consultant to apply knowledge of coding guidelines to determine validity of aberrances (SIU only)
  • Gather all relevant facts to articulate behavior through an Investigation Summary and compliance package.  Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders 
  • Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA to ensure additional TIP submission
  • Perform member and provider interviews, and review medical documentation as needed 
  • Communicate with legal, Law Enforcement, clients and business partners as needed

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:

  • Associate's Degree in the area of Criminal Justice or experience in a related field (or 5+ years of experience working in a FWA / SIU or Fraud investigations role for New Jersey/New York location)
  • 2+ years of experience within the health insurance claims industry
  • 2+ years of experience working with law enforcement or legal entities or 3-5 years Investigative experience with fraud investigations
  • 1+ years knowledge and/or experience with behavioral health codes and service delivery
  • Intermediate proficiency in Microsoft Excel (pivot tables and macros) and Word (documents)

Preferred Qualifications:

  • Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
  • Familiar with CPT code terminology
  • Experience with computer research
  • Experience with regulatory compliance
  • Experience with data analysis as it relates to financial recovery/settlements

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care 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)

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy

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: Sr. Investigator, Senior Investigator,   Telecommute, Telecommuting, Telecommuter, Work From Home, Remote, Nashville, Tennessee, TN 

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