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SIU Senior Investigator

Company: UnitedHealth Group
Location: Nashville
Posted on: May 29, 2023

Job Description:

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us and start doing your life's best work. SM

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.

If you reside in the state of Tennessee, you'll enjoy the flexibility to telecommute as you take on some tough challenges.

Primary Responsibilities:

  • 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, at the discretion of SIU leadership, to include attendance at work-groups or regulatory meetings
  • Ability to participate in legal proceedings, arbitrations, depositions, etc.
    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:
    • Bachelor's Degree (or higher) OR Associate's Degree (or higher) in criminal justice or related field
    • 5+ years in the healthcare field working in fraud, waste, and abuse investigations and audits, OR 5+ years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, OR 7+ years of professional investigation experience involving economic or insurance related matters
    • 2+ years of working knowledge of medical benefits, specialty benefits and pharmacy benefits
    • 2+ years of working knowledge of Compliance Program policies, procedures and documentation standards
    • 2+ years of experience with data manipulation within Excel
    • Advanced level of proficiency in Microsoft Excel and Word
    • Reside in the state of Tennessee with the ability to travel up to 25% of the time
      Preferred Qualifications:
      • Active affiliations:
        • National Health Care Anti-Fraud Association (NHCAA)
        • Accredited Health Care Fraud Investigator (AHFI)
        • Certified Fraud Examiner (CFE)
        • Certified Professional Coder (CPC)
          Soft Skills:
          • Excellent skills in developing investigative strategies
          • Ability to communicate effectively, to include written and verbal forms of communication
          • Ability to develop goals and objectives, track progress and adapt to changing priorities
            Careers with UnitedHealthcare. Work with a Fortune 5 organization that's serving millions of people as we transform health care with bold ideas. Bring your energy for driving change for the better. Help us improve health access and outcomes for everyone, as we work to advance health equity, connecting people with the care they need to feel their best. As an industry leader, our commitment to improving lives is second to none.

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

            For more information on our Internal Job Posting Policy, click here .

            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.

            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.


Keywords: UnitedHealth Group, Nashville , SIU Senior Investigator, Accounting, Auditing , Nashville, Tennessee

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