Lead Investigator - Telecommute in NE

Careers at UnitedHealth Group

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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

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The Program Integrity/Special Investigations Unit (PI/SIU) Lead Investigator for Nebraska and Arkansas will be responsible for detecting, investigating, and reporting suspected and/or confirmed cases of fraud, abuse or waste and coordinating investigative matters impacting the company as well as training and supporting the SIU Investigators within the unit. Will also increase the effectiveness of the company-wide investigations by communicating, mentoring and building solid relationships within all departments of the company.

Primary Responsibilities:
  • Gathers information from Profiling/Fraud Analyst, external sources, and from electronic databases and directs investigations related to suspected insurance fraud
  • Investigates allegations and issues pertaining to potential health care fraud by providers or members
  • Documents investigations, including comprehensive preliminary and final case reports for both internal tracking and regulatory reporting purposes
  • Generates leads for fraud investigations and analyzes claims data to detect fraudulent activity
  • Develops company awareness program focused on the cost and frequency of health insurance fraud, and methods by which the company can prevent it
  • Facilitates corporate fraud, waste and abuse training and creates specialized departmental training programs
  • Coordinates with internal departments to further fraud investigations, including a periodic review of claims and forms for the purpose of enhancing the ability of the company to detect fraud and to increase the likelihood of its successful prosecution, and for initiation of civil actions where appropriate
  • Makes recommendations relating to claims edits and other cost saving measures
  • Consults with management and/or in-house counsel as needed to resolve difficult or complex compliance issues
  • Identifies risks, interprets investigation results, and recommends and communicates remedial actions to mitigate future potential risks. Performs follow up to ensure remedial / disciplinary measures are implemented appropriately and timely
  • Prepares cases for referral to state and federal agencies
  • Plans, develops, leads, and manages multiple projects, including prioritizing and managing through execution. Thoroughly documents, organizes, and reviews case files, electronic and hardcopy, relative to each investigation in accordance with Company policy and ensures remediation activities are tracked and implemented
  • Maintains a high degree of integrity and confidentiality
  • Maintains knowledge about all applicable local, state and federal fraud statutes in order to ensure duties and assignments are carried out within the requirements of applicable laws
  • Develops and maintains positive working relationships with federal, state and local law enforcement agencies
  • Provides training for new PI/SIU Investigators and provides ongoing assistance, guidance and support for all PI/SIU Investigators
  • Receives and reviews all internal profiling reports in order to track and delegate caseloads to PI/SIU Investigators
  • Ensures that all PI/SIU investigative reporting requirements are being met
  • Tracks case information and completes necessary reporting schedules and prepares monthly and quarterly reports
  • Ensuring all investigative information gets appropriately reported for each states reporting mechanism
  • Liaison with offsite clinical reviewers
  • Liaison between PI/SIU Investigators and State Agencies/Law Enforcement for final referral of cases to ensure reporting consistency
  • Conducts monthly and quarterly audits of the cases in the SIU Case Management System
  • Performs special projects as necessary
  • Assists the PI Officer with administrative tasks as needed

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:
  • Associate's or bachelor's degree in criminal justice or a related field
  • Authorized dental professional to evaluate dental related claims
  • Full COVID-19 vaccination is an essential requirement of this role. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance

Preferred Qualifications:
  • 3+ years of insurance claims investigation experience or professional investigation experience with law enforcement agencies
  • 3+ years of professional investigation experience involving economic or insurance related matters

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies now require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles require full COVID-19 vaccination as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Careers at Managed Care of North America, Inc. (MCNA), part of the UnitedHealthcare and UnitedHealth Group family of businesses. MCNA is a leading dental benefits administrator dedicated to promoting high quality and cost-effective oral health. We provide services to state agencies and managed care organizations for Medicaid, Children's Health Insurance Program (CHIP) and Medicare members. We also offer commercial plans for private employers, individuals and families. Join our team and help us make dental care more accessible to everyone. Our career opportunities span across different job categories and specializations, requiring a varying level of skills. Working with us means being part of a stable organization with meaningful purpose that will support your personal and professional development. This is an opportunity to make a difference in the lives of others while growing your career with a company that services over 8 million people. Become part of a team that has a passion for excellence and start doing your life's best work.(sm)

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: Program Integrity or Special Investigations Unit (PI or SIU) Lead Investigator, Lead Investigator, Program Integrity, Special Investigations Unit, Lincoln, NE, Nebraska

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