Investigator, New Mexico

About the Role

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities, and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable, and equitable.

The Investigator is responsible for identification, investigation, and prevention of healthcare fraud, waste, and abuse.

• Reside in the state of New Mexico for telecommuting flexibility.
• Schedule: Monday-Friday 8:00 AM - 4:30 PM CST

Key Responsibilities

• Assess complaints of alleged misconduct.
• Investigate low to medium complex cases of fraud, waste, and abuse.
• Detect fraudulent activity by members, providers, employees, and other parties against the Company.
• Develop and deploy the most effective and efficient investigative strategy for each investigation.
• Maintain accurate, current, and thorough case information in the Special Investigations Unit's (SIU's) case tracking system.
• Collect and secure documentation or evidence and prepare summaries of findings.
• Participate in settlement negotiations and/or produce investigative materials.
• Collect, collate, analyze, and interpret data relating to fraud, waste, and abuse referrals.
• Ensure compliance of applicable federal/state regulations or contractual obligations.
• Report suspected fraud, waste, and abuse to appropriate federal or state government regulators.
• Comply with goals, policies, procedures, and strategic plans as delegated by SIU leadership.
• Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at workgroups or regulatory meetings.
• Communicate effectively, including written and verbal forms of communication.
• Develop goals and objectives, track progress, and adapt to changing priorities.
• Must participate in legal proceedings, arbitration, and depositions at the direction of management.
• Conduct investigations which may include fieldwork to perform interviews and obtain records and/or other relevant documentation.
• Utilize claims data, applicable guidelines, and other sources of information to identify aberrant billing practices and patterns.

Requirements & Tech Stack

• Microsoft Excel (Intermediate proficiency)
• Microsoft Word (Intermediate proficiency)

Qualifications

• Associate's degree
• Ability to travel up to 25%.
• Access to reliable transportation.
• Valid US driver's license.

Preferred Qualifications

• Experience in health care fraud, waste, and abuse (FWA) investigations/audit.
• Experience with state/federal laws and regulations pertaining to healthcare FWA.
• Experience in analyzing data to identify fraud, waste, and abuse trends.
• Knowledge/training in healthcare FWA investigations.
• Active affiliations with the National Health Care Anti-Fraud Association (NHCAA).
• Accredited Health Care Fraud Investigator (AHFI).
• Certified Fraud Examiner (CFE).
• Certified Professional Coder (CPC).
• Medical Laboratory Technician (MLT).
• Statistical Analysis.