1+ months

Sr. Investigator - Telecommute in TN - 902758

Nashville, TN 37201 Work Remotely
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UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

Energize your career with one of Healthcare's fastest growing companies.

You dream of a great career with a great company - where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it's a dream that definitely can come true. Already one of the world's leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up.

This opportunity is with one of our most exciting business areas: UnitedHealthcare - a growing part of our family of companies that make UnitedHealth Group a Fortune 7 leader.

UnitedHealthcare helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.

Here's a statistic that will stop you cold: Our country spends nearly $3 trillion on health care annually. With that kind of money at play, you can be sure some individuals will figure out a way to get a piece of it illegally. Now, that doesn't even take into account the millions of lives that are held in the balance as well. This is fraud on a scale you couldn't begin to imagine. As a Senior Investigator, you will play a part in putting a stop to it. It's critical work that that you will want to be a part of. Apply today.

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 TN, ideally in Nashville, 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
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  • Utilize appropriate documentation and tracking controls in the case tracking system to ensure compliance and auditability requirements are met
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  • Collaborate with clinical coding consultant to apply knowledge of coding guidelines to determine validity of aberrances (SIU only)
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  • 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
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  • Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA to ensure additional TIP submission
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  • Perform member and provider interviews, and review medical documentation as needed
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  • Communicate with legal, Law Enforcement, clients and business partners as needed
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  • Recommend TIN shutdowns / hard deny flags to Fraud Flag Committee

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 (or higher) in the area of Criminal Justice (or related field) OR High School Diploma / GED (or higher) with other nationally recognized healthcare certification
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  • 2+ years of experience within the health insurance claims industry
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  • 2+ years of experience working with law enforcement or legal entities or 3+ years Investigative experience with fraud investigations
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  • Intermediate proficiency in Microsoft Excel (use of pivot tables and macros) and Microsoft Word (create, edit and save documents)
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  • If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking orders

Preferred Qualifications:
  • Professional Investigator (AHFI), or similar
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  • Experience with computer research
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  • Experience with data analysis as it relates to financial recovery / settlements
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  • Familiar with CPT code terminology

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 7 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)

*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, Investigator, Health Insurance Claims, Heath Insurance, Claims, Law Enforcement, Legal Entity, Legal, Law, Investigative, Nashville, TN, Tennessee, Telecommute, Telecommuting, Telecommuter, Work From Home, Remote
Posted: 2020-12-16 Expires: 2021-02-13

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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Sr. Investigator - Telecommute in TN - 902758

UnitedHealth Group
Nashville, TN 37201

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