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Senior Investigator - Remote in North Carolina - Winston Salem North Carolina
Company: UnitedHealthcare Location: Winston Salem, North Carolina
Posted On: 04/26/2024
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 to start Caring. Connecting. Growing together. 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 North Carolina, 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
- Communicate effectively, to include written and verbal forms of communication
- Develop goals and objectives, track progress and adapt to changing priorities
- 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 workgroups or regulatory meetings 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) AND 2+ years of healthcare related work experience
- Intermediate level of knowledge OR 2-5 years of experience in health care fraud, waste, and abuse (FWA)
- Intermediate level of knowledge OR 2-5 years of experience in state or federal regulatory FWA requirements
- Intermediate level of knowledge OR 2-5 years of experience analyzing data to identify fraud, waste and abuse trends
- Intermediate level of proficiency OR 2-5 years of experience in Microsoft Excel and Word
- Ability to participate in legal proceedings, arbitration, and depositions at the direction of management
- Currently reside within the state of North Carolina OR the ability to relocate at your own expense
- Ability to travel up to 25% of the time Preferred Qualifications:
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