Special Investigation Unit – Investigator – National Remote

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.  

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

UMR, UnitedHealthcare’s third – party administrator (TPA) solution, is the nation’s largest TPA. When you work with UMR, what you do matters. It’s that simple . . . and it’s that rewarding.

In providing consumer – oriented health benefit plans to millions of people; our goal is to create higher quality care, lower costs and greater access to health care. Join us and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system. Opportunities are endless for your career development and advancement within UMR due to our record – breaking growth.

Regardless of your role at UMR, the support you feel all around you will enable you to do what you do with energy, quality, and confidence. So, take the first step in what is sure to be a fast – paced and highly diversified career. 

Special Investigation Unit – State Investigators are tasked with the responsibility of detecting, investigating, and determining future action on potential fraudulent billing activity. We are seeking a candidate who is curious, innovative, and passionate about serving our customers by reducing the total cost of health care. Strong communication skills and the ability to thrive in a changing environment are essential. As part of our Payment Integrity team, you’ll help understand, evaluate, and prevent payments made in situations with fraud, waste, abuse, and errors. You’ll have all the tools and backing you need to help analyze claims and ensure adherence to procedures and compliance policies. All the while, you’ll be building your career with a leader and reaching for the highest levels of performance as you do your life’s best work.^SM

This position is full-time (40 hours / week), Monday – Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules (alternate schedule: they are flex time and could work 4x 10-hour shift from Monday – Friday as long as they are working the hours per business need) during our normal business hours of 7:00 AM – 5:00 PM. It may be necessary, given the business need, to work occasional overtime.

We offer weeks of paid on-the-job training. Duration is dependent on needs of candidate. The hours during training will be any of our 8-hour shift schedules (alternate schedule: they are flex time and could work 4x 10-hour shift from Monday – Friday as long as they are working the hours per business need) during our normal business hours of 7:00 AM – 5:00 PM.

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

Primary Responsibilities:

• Detect, analyze and investigate complex types of fraud, waste, abuse, and error activity
• Evaluate referrals and information from multiple data sources to determine if fraud, waste and abuse is suspected and what investigation is required
• Organize assigned service specific edit reviews, securing needed information, completing prepayment claim reviews and document findings.
• Conduct highly complex and confidential investigations, including coordination with other investigators for cases during initial and ongoing investigation, escalations, and closure
• Communicate case updates to internal stakeholders, escalating when appropriate
• Work independently

This is a challenging role with serious impact. You’ll need to sort through complex situations to understand and clarify where errors happened or where they may continue to happen. It’s a fast – paced environment that takes focus, intensity and resilience.

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:

• High School Diploma / GED OR equivalent experience
• Must be 18 years of age OR older
• 1+ years of experience with analyzing and solving customer problems 
• Experience with using Microsoft Word, Microsoft Excel, and Microsoft Outlook (Ability to create, edit, copy, send, and save documents, spreadsheets, and correspondence)
• Ability to work any of our 8-hour shift schedules (alternate schedule: they are flex time and could work 4x 10-hour shift from Monday – Friday as long as they are working the hours per business need) during our normal business hours of 7:00 AM – 5:00 PM. It may be necessary, given the business need, to work occasional overtime.
• Experience working with GEHA members

Preferred Qualifications:

• 3+ years of current OR previous UMR CPS / Jacada experience (UMR is UnitedHealthcare’s third – party administrator (TPA) solution and candidate must be a previous OR current employee of UMR / UHSS specifically to have the required experience with the UMR CPS system)
• Experience with working in the healthcare industry
• Knowledge of medical claims billing (ICD – 10, CPT, and / OR HCPC codes)
• Familiarity with resources such as EncoderPro, Knowledge Library, and / OR UMR Policies and Procedures

Telecommuting Requirements:

• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
• Ability connect directly into internet - via hard wire (either directly to modem or router)

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.

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