AtUnitedHealth Group, we combine two of the fastest growing fields on the planet,health care and technology, with UnitedHealth Group's culture of performance,collaboration and opportunity. The result is industry-leading health careservices at a company that's improving the lives of millions. TheFraud Investigator will design anddevelop reports and analyze data to measure clinical outcomes, networkperformance and methodology levers. You will investigate key business problemsthrough quantitative analyses of utilization and health care costs data. Youwill interpret and analyze clinical data from various sources and recommendbest approaches for its consolidation. Your analysis will be used to createviable, real-world solutions in a complex health care landscape. Join us.There's never been a better time to do your life's best work. (sm) As the FraudInvestigator, you will provide an organized approach to the prevention,detection, and reporting of fraud, waste, and abuse. Primary responsibilitiesfor this position are to perform the analysis, assessment and monitoringactivities related to the detection of fraud, waste, and abuse of medicalclaims. PrimaryResponsibilities: Correctly identify fraud, waste,abuse, and other schemes designed to incorrectly maximize payment of medicalclaimsLogically connect claim eventspatterns in order to create cases for investigationReview and interpret output fromprovider-centric detection engines (rules, models, or other scoring technique)Conduct independent research throughboth internal & external sources, tools, and databases in order to identifyaberrant providersConduct an assessment of incominglead referrals, and complete related documentationUse analytics to identify andexamine new patterns of fraud and abuseIdentify links between different fraudulentor abusive providersConduct independent research throughboth internal & external sources and databasesConduct an assessment of incominglead referrals, and complete related documentationPerform data analysis of claimshistory to substantiate fraud and abuse allegationsAccurately classify providerbehaviors as suspect or fraudulent, and clearly articulate the reasoning behindthese decisionsUnderstand aberrant billing patternsand quickly identify unusual provider behaviorPrepareaccurate reports to detect and identify new fraud trends, analysis of thosetrends and risk mitigation recommendations.Create presentations of findings forclientsCreate and update automatedprocesses within databasesUse reporting tools to analyze largedata sets Assistleadership staff in developing and maintaining specific work procedures,policies and process improvement projectsReportsactivities to leadership on a regular basis
Bachelor's degree or equivalent workexperienceHealth care experience in a medicalclaims environmentKnowledge of medical claimsStrong inductive and deductivereasoning skillsStrongattention to detail, solid analytical, problem solving and organizationalskillsProficiency in performing dataanalysis with an abilityto analyze and trend dataProficientin Microsoft Office software (Word, Excel, Access, PowerPoint)ExcelIntermediate skill level that includes formulas,calculations, pivot tables, charts, graphs, etc.At least a beginner levelproficiency with SQL, SAS and/or other statistical programs Nice to have: Knowledge of Medical CodingSAS certificationExperiencein health care fraud detection, investigation or prosecutionKnowledgeof a public sector health plan experienceExperiencewith process improvement projects and ability to plan/direct projectsKeywords: Fraud Investigator, SQL, SAS, HealthCare, MedicalClaims, Medical Coding, Microsoft Excel, Analytics, Claims Investigation,Financial Fraud Investigation, Medical Modelling.
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.