Healthcare Claims or Fraud Investigator - Taguig City, NCR

Careers at UnitedHealth Group

We're creating opportunities in every corner of the health care marketplace to improve lives while we're building careers. At UnitedHealth Group, we support you with the latest tools, advanced training and the combined strength of high caliber co-workers who share your passion, your energy and your commitment to quality. Join us and start doing your life's best work. SM

Clinical

Compassion. It's the starting point for health care providers like you and it's what drives us every day as we put our exceptional skills together with a real feeling of caring for others. This is a place where your impact goes beyond providing care one patient at a time. Because here, every day, you're also providing leadership and contributing in ways that can affect millions for years to come. Ready for a new path? Learn more, and start doing your life's best work. SM

Our teams are helping people from around the world. We can bring out your best as you put your listening, analytical and problem solving skills to work in a setting that is geared to helping improve lives and enhance health care for millions. Here, you'll discover a wealth of pathways for professional growth within Customer Service, Billing, Claims, Enrollment & Eligibility and across our global economy. Join us and find out why this is the place to do your life's best work. SM

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

Employees are responsible for triaging, investigating and resolving instances of healthcare fraud and/or abusive conduct by medical professionals. Using information from tips and complaints from plan members, the medical community and law enforcement, employee's conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. May conduct onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. Identify, communicate and recover losses as deemed appropriate. Where applicable, testimony regarding the investigation may be required. May also complete root cause analysis.

Jobs in this function provide coding and coding auditing services directly to providers. This includes the analysis and translation of medical and clinical diagnoses, procedures, injuries, or illnesses into designated numerical codes. Some work is completed without established procedures. Basic tasks are completed without review by others. Supervision/guidance is required for higher level tasks. *Employees in jobs labeled with 'SCA' must support a government Service Contract Act (SCA) agreement.

Primary Responsibilities:
  • Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so


Required Qualifications:
  • Graduate of any 4-year course, or Associate's degree in Criminal Justice (or a related degree) plus minimum of 2 years of experience with insurance related employment
  • 7+ years of professional investigation experience involving economic or insurance related matters (or)
  • 5+ years of insurance claims investigation experience (or)
  • 5+ years of professional investigation experience with law enforcement agencies
  • Experience with one or more of the following

- Claims processing
- Provider demographic information
- Insurance billing practices
  • Experience using claims platforms such as UNET, Pulse, NICE, Facets, Diamond, etc.
  • Moderate work experience within own function
  • Intermediate to advanced experience with Microsoft Office - Microsoft Excel (sort and filter data) and Microsoft Word (create and edit documents)


Preferred Qualifications:
  • Preferably with working internet connection of at least 15 mbps in case of working from home. The following options are also available:

- Corporate internet subsidy for those within available and valid serviceable locations, subject to Company Policy
- Onsite work for those who are amenable to drive or commute to our office locations

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

Diversity creates a healthier atmosphere: Optum 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.

Optum is a drug-free workplace. © 2021 Optum Global Solutions (Philippines) Inc. All rights reserved.

Job Keywords: Healthcare Claims Investigator, Fraud Investigator, Healthcare Claims or Fraud Investigator, Healthcare Claims, Fraud, Insurance, Professional Investigation, Investigation, Claims Processing, Provider Demographic Information, Insurance Billing, UNET, Pulse, NICE, Facets, Diamond, Taguig City, NCR, National Capital Region

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