Senior Investigator

Optum; Arlington (VA); On-site; USD 60,000 - 107,000; Full time

Job summary

Optum is seeking a seasoned investigator to support SIU/FWA efforts in Virginia. You will analyze data and evidence, interview members and providers, and prepare investigation summaries for clients, regulators, and stakeholders.

This role requires 5+ years in FWA or fraud investigations, experience with health insurance claims, and the ability to travel 25% within Virginia for on-site visits. A High School Diploma or GED is required; professional certifications are a plus.

Qualifications

• 5+ years of experience in a FWA/SIU or Fraud investigations.
• 2+ years of experience within the health insurance claims industry.
• 2+ years of experience with law enforcement or legal entities or 3+ years of investigative experience with fraud investigations.
• 1+ years of knowledge/experience with behavioral health codes and service delivery.

Responsibilities

• Gather and analyze data to determine behavior and understand provider/scheme at issue.
• Utilize documentation and tracking controls in the case tracking system to ensure compliance and auditability.
• 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 rationale to Client, Regulator and stakeholders.
• Collaborate with external sources to identify current and emerging patterns related to 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.

Skills

Fraud investigations

Health insurance claims

Interviewing

Legal coordination

Travel 25% within VA

Microsoft Excel

Microsoft Word

Education

High School Diploma/GED

Tools

Microsoft Excel

Pivot tables

Macros

Word

Job description

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

If you reside in Virginia, you will have the flexibility to work remotely* 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 to 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 directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications

• High School Diploma/GED
• 5+ years of experience working in a FWA / SIU or Fraud investigations
• 2+ years of experience within the health insurance claims industry
• 2+ years of experience working with law enforcement or legal entities or 3+ years of Investigative experience with fraud investigations
• 1+ years of knowledge and/or experience with behavioral health codes and service delivery
• Intermediate level of proficiency in Microsoft Excel (pivot tables and macros) and Word (documents)
• Ability to travel 25% of the time in the state of Virginia for client on-site visits
• Reside in the state of Virginia

Preferred Qualifications

• Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
• Experience with computer research
• Experience with regulatory compliance
• Experience with data analysis as it relates to financial recovery/settlements
• Familiar with CPT code terminology
• All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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