Senior Investigator - Remote in Nebraska

UnitedHealth Group; Omaha (NE); Remote; USD 59,000 - 117,000; Full time

Job summary

Join a forward-thinking organization dedicated to improving healthcare equity and outcomes. In this role, you will investigate potential healthcare fraud and abusive conduct, utilizing your expertise in data analysis and collaboration with law enforcement. You'll work in a supportive environment that values diversity and offers comprehensive benefits, including stock options and 401k contributions. This position allows for remote work flexibility, making it an ideal opportunity for those looking to make a meaningful impact while enjoying a balanced work-life dynamic. If you're passionate about healthcare and fraud prevention, we want to hear from you!

Benefits

Comprehensive benefits package

Incentives

Stock purchase options

401k contributions

Qualifications

• 5+ years in FWA/SIU or 3+ years in fraud investigations.
• Proficiency in MS Excel and MS Word is required.

Responsibilities

• Investigate potential healthcare fraud and abusive conduct.
• Gather and analyze data to understand provider behavior.
• Conduct interviews and review medical documentation.

Skills

FWA/SIU experience

Fraud investigations

Healthcare claims knowledge

Law enforcement collaboration

Behavioral health codes knowledge

Data analysis

MS Excel proficiency

MS Word proficiency

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 diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

It is Optum’s mission and intent to protect members, providers, business partners, employees, and stakeholders by administering a solid 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 through technologically advanced tools and a 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, which works with Providers to identify billing and payment patterns and trends requiring education or process modifications. Together with Providers, Optum is committed to identifying and remediating potential Fraud, Waste, Abuse, and Error (FWA) and Payment Integrity Issues.

Employees are responsible for triaging, investigating, and resolving potential healthcare fraud and/or abusive conduct by medical professionals or providers. Using information from tips, complaints, external intelligence, or behavior data, employees conduct confidential investigations, document findings, and report illegal activities in accordance with all laws and regulations. They may request onsite provider claims or clinical audits to gather and analyze relevant information. Investigations may include interviews with providers, members, legal, compliance, and law enforcement, requiring adherence to all applicable policies. Testimony in court may be required, and root cause analysis may be performed.

If you are located in Nebraska, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

1. Gather and analyze data to understand provider behavior and schemes at issue.
2. Use documentation and tracking controls in the case system to ensure compliance and auditability.
3. Collaborate with clinical coding consultants to apply coding guidelines and determine the validity of aberrations (SIU only).
4. Compile facts into Investigation Summaries and compliance packages, communicating processes and outcomes clearly to stakeholders.
5. Work with external sources to identify emerging FWA patterns and ensure TIP submissions.
6. Conduct interviews and review medical documentation as needed.
7. Respond to inbound calls from members and providers.
8. Communicate with legal, law enforcement, and clients as necessary.
9. Perform provider onsite audits to gather and analyze information.

You’ll be rewarded and recognized for your performance in an environment that challenges you, provides clear success indicators, and offers development opportunities.

Required Qualifications:

• 5+ years of experience in FWA/SIU or 3+ years in fraud investigations.
• 2+ years working with healthcare claims, managed care, or health insurance.
• 2+ years working with law enforcement or legal entities, or 3+ years in investigative roles.
• 1+ years of knowledge of behavioral health codes and services.
• Proficiency in MS Excel (pivot tables, formulas, functions).
• Proficiency in MS Word.
• Residence in Nebraska.

Preferred Qualifications:

• Professional certifications like CFE, AHFI, or similar.
• Familiarity with CPT codes.
• Experience with computer research and regulatory compliance.
• Experience with data analysis related to financial recovery.

*Remote work is subject to UHG’s Telecommuter Policy.

The salary range is $59,500 to $116,600 annually, based on various factors. UHG offers a comprehensive benefits package, incentives, stock purchase options, and 401k contributions. Benefits are subject to eligibility.

Our mission is to help people live healthier lives and improve healthcare equity. We are committed to diversity, environmental sustainability, and equitable care, addressing health disparities and outcomes.

UHG is an Equal Opportunity Employer, and all qualified applicants will receive consideration without regard to protected characteristics. We are a drug-free workplace, and candidates must pass a drug test before employment.