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.
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 to include attendance at work-groups and regulatory meetings
- To be considered for this position, applicants need to meet the qualifications listed in this posting and reside in Philadelphia, PA, Horsham, PA or Iselin, NJ, or New York City*
Bachelor’s degree or Associates degree plus two years of equivalent work experience with healthcare related employment
Intermediate level of proficiency in Microsoft Excel and Word
An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy and/or commercial health insurance)
Must live within state of Pennsylvania, New Jersey, or New York
Must be willing and able to travel up to 25% of the time
Specialized knowledge/training in healthcare FWA investigations
Active affiliations with National Health Care Anti-Fraud Association (NHCAA)
Accredited Health Care Fraud Investigator (AHFI)
Certified Fraud Examiner (CFE)
Certified Professional Coder (CPC)
Medical Laboratory Technician (MLT)
Intermediate knowledge in Medical claims
Operational experience with medical investigations
Experience with claims processing systems
Broad knowledge and experience in health care fraud, waste and abuse (FWA) investigations
Broad knowledge and experience in state and federal regulatory FWA requirements
Above average skills in data manipulation
Excellent skills in developing investigative strategies.
Demonstrated ability to supervise a team
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 participate in legal proceedings, arbitrations, depositions, etc.
At UnitedHealth Group, we're in the business of helping millions live healthier lives. Our customers need somewhere to turn to for answers about their health. Come help us protect the integrity of the health care system as you do your life's best work.(sm)
Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 5 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.