Job Information
UnitedHealth Group Principal Medical FWA Investigator **Must Reside in Kentucky** in Louisville, Kentucky
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. Ready to make a difference? Join us to start Caring. Connecting. Growing together.
The Principal Investigator reports directly to the Manager of Investigations. The Principal Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste, and abuse. The Principal Investigator will utilize claims data, applicable guidelines, and other sources of information to identify aberrant billing practices and patterns. The Principal Investigator is responsible to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.
If you reside in KY you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
Investigate highly 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 the findings
Participate in settlement negotiations and/or produce investigative materials in support of the later
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, to include written and verbal forms of communication
Develop goals and objectives, track progress and adapt to changing priorities
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:
Bachelor's degree or higher
Demonstrated advanced level of knowledge in health care fraud, waste and abuse (FWA) or 5+ years of experience, 3 of which must be specific to Medicaid Fraud
Demonstrated advanced level of knowledge in state or federal regulatory FWA requirements or 5+ years of experience
Demonstrated advanced level of knowledge analyzing data to identify fraud, waste and abuse trends or 5+ years of experience
Demonstrated advanced level of proficiency in Microsoft Excel and Word or 5+ years of experience
Proven ability to participate in legal proceedings, arbitration, and depositions at the direction of management
Willing or ability to travel up to 25% as needed throughout the state of KY
Preferred Qualifications:
Demonstrated intermediate level of knowledge in health care policies, procedures, and documentation standards or 5+ years of experience
Demonstrated intermediate level of skills in developing investigative strategies or 5+ years of experience
Specialized knowledge/training in healthcare FWA investigations
Active affiliations:
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)
Advanced knowledge and experience in any of the following:
Statistical Analysis Software (SAS)
R
Python
Tableau
Toad
Structured Query Language (SQL)
Visual Basic for Applications (VBA)
Alteryx
Advanced knowledge and experience in any of the following:
Statistical Analysis
Regression Analysis
Linear Analysis
Market-basket Analysis
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.
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.
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