Investigator

About the Role

At UnitedHealthcare, we are dedicated to streamlining health care, fostering healthier communities, and eliminating barriers to quality care. The Investigator will play a vital role in detecting, investigating, and preventing healthcare fraud, waste, and abuse by analyzing claims data and other relevant information. This position is fully remote, allowing work from anywhere in the U.S.

Key Responsibilities

• Evaluate complaints regarding alleged misconduct within the organization.
• Conduct investigations of low to medium complexity involving fraud, waste, and abuse activities.
• Identify fraudulent behaviors by members, providers, employees, and other entities.
• Formulate and implement the most effective investigative strategies on a case-by-case basis.
• Maintain detailed and current records in the Special Investigations Unit’s case tracking system.
• Gather evidence and documentation, preparing comprehensive summaries of findings.
• Engage in settlement discussions or support these negotiations with detailed investigative documentation.
• Analyze data from referrals related to fraud, waste, and abuse to identify patterns.
• Ensure adherence to federal and state regulations, as well as contractual obligations.
• Report suspected fraudulent activities to the appropriate governmental agencies.
• Follow guidelines, goals, and policies set by SIU leadership.
• Work collaboratively with state and federal partners, including participation in workgroups and regulatory meetings when requested.
• Communicate effectively using both written and verbal methods.
• Establish, track, and adjust goals and objectives according to evolving priorities.
• Participate in legal processes such as arbitration, depositions, and court proceedings as directed.

Qualifications

• Associate’s degree or higher education level required.
• Minimum of one year’s experience investigating healthcare fraud, waste, and abuse or conducting audits.
• Basic understanding and training in healthcare fraud, waste, and abuse investigations.
• Familiarity with relevant federal and state laws and regulations related to healthcare fraud.
• Competence in analyzing data for fraud, waste, and abuse trends.
• Willingness and ability to travel up to 25% of the time.
• Proficiency at an intermediate level with Microsoft Excel and Word.

Preferred Qualifications

• Membership with the National Health Care Anti-Fraud Association (NHCAA).
• Certifications such as AHFI (Accredited Health Care Fraud Investigator), CFE (Certified Fraud Examiner), CPC (Certified Professional Coder), CPhT (Certified Pharmacy Technician), or MLT (Medical Laboratory Technician).
• Experience with statistical data analysis.
• Adherence to the company’s telecommuting policies for remote workers.

Compensation and Benefits

The annual salary for this position ranges from $49,700 to $88,800, depending on location, education, experience, and certifications. Employees also receive comprehensive benefits, incentive programs, stock purchase options, and 401(k) contributions, subject to eligibility. The organization complies with all applicable minimum wage laws.

Diversity and Inclusion

UnitedHealth Group is committed to equal employment opportunity without discrimination based on race, origin, religion, gender identity, age, disability, veteran status, or any other protected characteristic. They also welcome applicants with arrest and conviction records in accordance with the San Francisco Fair Chance Ordinance.

Additional Information

This is a drug-free workplace, requiring candidates to pass a drug screening prior to employment. The job posting will remain open for a minimum of two business days or until a sufficient pool of candidates is identified, with the possibility of earlier closure due to high application volume.

Company Mission

UnitedHealth Group aims to help people achieve healthier lives and improve the health system for everyone. They emphasize mitigating environmental impact and providing equitable care that addresses health disparities.