Position Description: You'll join a high caliber team where you're assisting, educating, problem-solving and resolving tenuous situations to the best possible outcomes. Bring your people skills, emotional strength and attention to detail. In return we offer the latest tools and most intensive training program in the industry. Get ready to start doing your life's best work.(sm)The Audit & Recovery Investigator will be responsible for triaging, investigating and resolving instances of healthcare fraud and / or wasteful and abusive conduct by health care providers who submit claims for payment. This position will be utilizing information from claims data analysis, plan members, the medical community, law enforcement, employee conduct, and confidential investigations in order to document relevant findings. The investigator will conduct onsite and desk audits of provider claims and / or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documentation related to the investigation, and prepare all necessary reports. The investigator will input information into Optum audit workflow tools and the client's case tracking system. The investigator will act as a subject matter expert in identifying, communicating and recouping improper payments as deemed appropriate. Where applicable, the investigator will provide appeals and investigative support, as well as testimony. Primary Responsibilities:Investigate, audit, and resolve all types of Medicaid claims as well as recovery and resolution for government payersProcess recovery on claimsEnsure adherence to state and federal compliance policies, reimbursement policies, and contract complianceUse pertinent data and facts to identify and solve a range of problems within area of expertiseThe successful candidate will be part of a group of auditors deployed to investigate possible fraud, waste and abuse in MassachusettsGenerally work is self-directed and not prescribedWorks with less structured, more complex issuesServes as a resource to others and as a lead to analyst positions
Requirements: Associate's Degree or higherProfessional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or clinical expertise (RN) or similar4+ years of experience with auditing and monitoring in healthcare claimsExperience with MS Excel including data entry, sorting, creating / modifying spreadsheets, Vlookup, and formulasUp to 25% travel requiredAssets:Familiarity with CPT-4, HCPCs and ICD-9 / 10 code terminologyExperience with data analysis as it relates to financial recovery / settlementsMS Access (create and modify queries and reports)Knowledge of Medicaid / Medicare Reimbursement methodologiesKnowledge of claims processing systems (general knowledge in how claims are processed) and guidelines / processesExperience working with long-term services and supports provided by MedicaidExperience working with state Medicaid programsCareers 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.SMDiversity 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. Keywords: UHG, UnitedHealth Group, claims, Recovery Resolutions Consultant, Boston, Massachusetts, Medicaid, Medicare, claims processing, healthcare, customer service
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.