Program Integrity Manager - Telecommute in IA or NE

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


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

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

UnitedHealthcare Community & State, part of the UnitedHealth Group family of companies, is looking for an experienced Health Plan Program Integrity / Fraud, Waste and Abuse Compliance Consultant to join our dynamic Compliance team. The Compliance Consultant is an individual contributor role responsible for fraud, waste and abuse and specific research leading to best practice policy implementation and vendor/subcontractor monitoring to drive problem/process resolution for the Nebraska Medicaid health plan.

If you are located in the state of Iowa or Nebraska, you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:
  • Works to ensure that internal processes are executed, especially related to intersegment responsibilities, for fraud, waste, and abuse (FWA) vendors' instances of health care FWA by medical profession or insured member
  • Acts as FWA subject matter expert for Federal and local FWA regulations and subsequent regulatory policy and process implementation
  • Responsible for keeping apprised of current, proposed, and new federal and state regulations / guidelines
  • Ensures that changes in requirements are included in education and carried out by required audiences
  • Serves as health plan FWA trainer. Coordinates and supports implementation of FWA training and educational programs with the appropriate business areas and vendors
  • As necessary, gather and analyze all information and documents related to a FWA investigation
  • Acts as health plan FWA vendor liaison, i.e., conducts reviews on policies to make sure they are compliant; ensures that vendor processes are executed appropriately; that timelines are met per regulatory fulfillment; sets boundaries for vendors so that accountabilities are clear.
  • Serves as regulatory FWA liaison to the regulatory entities and internally to key FWA organizational partners, including participation in meetings with regulators
  • Develops and maintains fraud-related policies, e.g., documents the education and hand-offs for the health plan from functional teams as required to meet contractual obligations
  • Oversees and ensures all required FWA regulatory reporting meets regulatory expectations
  • Ensures procedures are established to support timely communication and education regarding the fraud program
  • Ensures that procedures are in place to review and report possible violations in accordance with the reporting requirements as outlined in the FWA Plan. Reviews vendors to make sure that all aspects of FWA are managed and policies are developed where gaps are identified

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:
  • 2+ years of experience in a FWA, investigations, regulatory or compliance role, or related experience
  • 2+ years of experience working in a government, health care, managed care or insurance environment, or related experience
  • Intermediate or better proficiency using MS Word, MS Excel and MS PowerPoint

Preferred Qualifications:
  • Bachelor's degree or equivalent experience
  • 2+ years of experience auditing medical billing and coding
  • Proven record of ability to translate highly complex concepts in ways that can be understood by a variety of audiences
  • Ability to identify root cause issues and ensure appropriate corrective action
  • Demonstrated ability to communicate effectively in written and verbal English
  • Ability to manage multiple projects and multiple relationships across the matrix
  • Ability to stay organized and use time management skills
  • Ability to work effectively and congenially with employees at all levels

UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 5 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm)

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

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 Keywords: Compliance, Reporting, Regulatory, Telecommute, Telecommuting, Telecommuter, Work From Home, Work At Home, Remote, IA, Iowa, NE, Nebraska