SIU Lead Investigator

UnitedHealth Group; Minnesota; Remote; USD 73,000 - 130,000; Full time

Benefits offered by this job

Telecommuter policy

Job summary

UnitedHealth Group is seeking an experienced SIU Investigator to triage, investigate, and resolve healthcare fraud cases across the U.S. You will conduct interviews, gather evidence, and prepare comprehensive reports for compliance and legal review.

The role requires CPC/RHIT or equivalent certifications, 5+ years of FWA/SIU experience, and strong data analysis and Excel skills. Telecommuting from anywhere in the U.S. is supported, with salary competitive and benefits offered.

Qualifications

• High School Diploma or GED.
• CPC or RHIT certification.
• CFE/AHFI or similar certification preferred.
• 5+ years in FWA/SIU or fraud investigations.
• 2+ years in health insurance claims.
• 2+ years with medical/behavioral health codes.
• 2+ years with law enforcement or legal entities.
• 2+ years in data analysis related to financial recovery.

Responsibilities

• Perform root-cause and trend analysis to prevent fraud.
• Document investigations and prepare compliance packages.
• Collaborate with external sources to identify schemes.
• Mentor investigators and deliver leadership presentations.
• Maintain confidentiality and data handling compliance.
• Track SIU metrics and report findings.

Skills

Data analysis

Excel (Pivot/Macros)

Interviews & evidence

Communication skills

Case management

Education

High School Diploma / GED

Associate degree in Criminal Justice

Tools

Microsoft Excel

Microsoft 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 startCaring. Connecting. Growing together.

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. 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.

You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Perform root-cause and trend analysis and translate findings into prevention (policy recommendations, new detection rules, training opportunities, control improvements).
• Utilize appropriate documentation and tracking controls in the case tracking system to ensure compliance and auditability requirements are met
• Collaborate with SIU Investigator to apply knowledge of coding guidelines to determine validity of aberrances.
• Gather all relevant facts to articulate behavior through an Investigation Summary and compliance package.
• Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA
• Provide case direction and mentorship to investigators/analysts (work planning, quality checks, documentation standards, coaching on interviews and evidence development).
• Develop and deliver case presentations to leadership, clients, and compliance (case theories, evidence summaries, overpayment methodology, recommended outcomes
• Ensure confidentiality and data handling compliance (PHI/PII, minimum necessary, secure sharing, retention requirements) and coach others on the same.
• Maintain SOPs and training materials; lead calibration sessions to improve consistency in decisioning, documentation, and case outcomes.
• Track and report SIU metrics/KPIs (cycle time, recoveries, outcomes, inventory health, referral sources)
• 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
• Certified Professional Coder certification (CPC) or RHIT
• Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI) or similar certification
• 5+ years of experience working in a FWA / SIU or Fraud investigations role
• 2+ years of experience within the health insurance claims industry
• 2+ years of knowledge and/or experience with medical/behavioral health codes and service delivery
• 2+ years of experience working with law enforcement or legal entities or 3+ years of investigative experience with fraud investigations
• 2+ years of experience with computer research
• 2+ years of experience with regulatory compliance
• 2+ years of experience with data analysis as it relates to financial recovery/settlements
• Intermediate level of proficiency in Microsoft Excel (pivot tables and macros) and Word (creating, editing, and saving documents)
• Familiar with CPT code terminology

Preferred Qualifications:

• Associate degree in the area of Criminal Justice or experience in a related field

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

For more information on our Internal Job Posting 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 $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

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.

#RPO #GREEN

Application Deadline:

This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.