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Senior Healthcare Reviewer and Investigator Boise, ID

Company: United healthcare Group
Location: Boise
Posted on: October 12, 2020

Job Description:

Optum, a UnitedHealth Group company, with over 125,000 employees globally, specializes in tackling the biggest challenges in health care by partnering across the entire system. Together, we are transforming health care for a better future for everyone we serve. Here's a statistic that will stop you cold: our country will spend more than $8 trillion on health care in 2020. With that kind of money at play, you can be sure some individuals will figure out a way to get a piece of it illegally. Now, that doesn't even take into account the millions of lives that are held in the balance as well. This is fraud on a scale you couldn't begin to imagine. As a Senior Investigator, you will play a part in putting a stop to it. It's critical work that you will want to be a part of, and we're a place like no other and where you'll do your life's best work.(sm) Our Senior Investigators work on elite Avoidance Investigations Units (AIUs) / Special Investigations Units (SIUs), dedicated to identifying, investigating and eliminating healthcare fraud. You will be part of a team responsible for investigating and resolving instances of healthcare fraud and/or abusive conduct. You will spend your time conducting investigations and putting together your findings. This is an office-based position for our Boise, ID location. In this role, you will work collaboratively with Idaho state employees, and conduct onsite visits / audits and obtain medical records as part of investigations to validate provider claims. Part of our screening and selection process involves completing a HireVue video interview and a pre-interview questionnaire for consideration. Primary Responsibilities: * Investigating and resolving instances of healthcare fraud, waste, and / or abusive conduct * Conduct telephonic interviews of members, providers, and/or additional contacts to gather information to support investigation * Review claims data and conduct analysis to look for patterns of potential fraud, waste and/or abuse * Utilizing information from claims data analysis, plan members, and other sources to conduct confidential investigations, document relevant findings and report any illegal activities in accordance with all laws and regulations * Conduct investigations to review claim and case history * Potentially conduct onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation * Collaborate and analyze all information gathered from our onsite team to document additional facts related to the investigation * Gather information pertinent to the case and provide testimonials regarding the investigation * Support Compliance, Regulatory, Legal, and Law Enforcement on case actions 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 plus 2+ years of experience working in a government, legal, law enforcement, investigations, healthcare, healthcare claims, investigating fraud, managed care and/or health insurance environment * or Undergraduate degree in the area of health care, business law, coding, criminal justice or related field * Previous knowledge and/or experience with health codes and service delivery * Intermediate proficiency with Excel including utilization of pivot tables, formulas, functions, etc. * You will be asked to perform this role in an office setting or other company location * If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas, In addition, employees must comply with any state and local masking orders. Preferred Qualifications: * Experience communicating complex information via phone conversations and emails to non-technical clients, providers, internal customers, outside law enforcement agencies and executives; must have solid ability to accurately document findings in written form * 3+ years of experience working in the health care and/or health insurance field * An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy and/or commercial health insurance) * ISET and/or Provider Profiler experience * Experience with NPPES, SIRIS, CLEAR and Secretary of State sites * Experience with iDRS (tracking system) or DOC 360 (or other claims imaging systems) * Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar * Certified Coding Specialist * Familiar with CPT code terminology * Experience with computer research * Experience with data analysis as it relates to financial recovery / settlements UnitedHealth Group is an essential business. The health and safety of our team members is our highest priority, so we are taking a science driven approach to slowly welcome and transition some of our workforce back to the office with many safety protocols in place. We continue to monitor and assess before we confirm the return of each wave, paying specific attention to geography-specific trends. We have taken steps to ensure the safety of our 325,000 team members and their families, providing them with resources and support as they continue to serve the members, patients and customers who depend on us. Some of the steps we've taken to ensure employee well-being include: * Launched our ProtectWell app and UnitedCARES program to help ease the burden and stress for our UnitedHealth Group team members and their immediate family affected by COVID-19 * Daily updates from our CEO Dave Wichmann to support and inspire team members during this challenging time * Onsite social distancing and increased sanitization measures for employees who have been welcomed back to our offices * Fully cover the COVID-19 healthcare costs for our employees * Employees who self-identify as high risk or who live with someone who is high risk have been asked to remain working from home You can learn more about all we are doing to fight COVID-19 and support impacted communities: click here. What we do defines who we are. Take a deeper look at how we're providing support during this global health crisis and search for a way you can get involved. View our COVID-19 Resources Page: click here. 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. Job Details * Requisition Number * Job Title Senior Healthcare Reviewer and Investigator - Boise, ID * Job Family Regulatory and Compliance * Business Segment OptumInsight Job Location Information * Boise, ID United States North America Additional Job Detail Information * Employee Status Regular * Schedule Full-time * Job Level Individual Contributor * Shift Day Job * Travel Yes, 25 % of the Time * Telecommuter Position No * Overtime Status Exempt

Keywords: United healthcare Group, Boise , Senior Healthcare Reviewer and Investigator Boise, ID, Healthcare , Boise, Idaho

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