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We have modest goals: Improve the lives of others. Change the landscape of health care forever. Leave the world a better place than we found it. Such aspirations tend to attract a certain type of person. Crazy talented. Compassionate. Driven. To these individuals, we offer the global reach, resources and can-do culture of a Fortune 5 company. We provide an environment where you’re empowered to be your best. We encourage you to take risks and in return, offer a world of rewards and benefits for performance. Exceeding your limits is an exceptional start to your life's best work.SM


Just like you, we are driven by a set of fundamental principles that are guiding our way forward. Our values of integrity, compassion, relationships, innovation, and performance serve as a foundation to transform health care. Are you in? Learn more about your future at UnitedHealth Group at careers.unitedhealthgroup.com


Job Category:

Regulatory and Compliance



Approximate Salary:

Not Specified

Position Type:

Full Time

Investigations Consultant - Miramar, FL (Office-Based)

UHG - Miramar, Florida

Posted: 11/12/2018

Bring us your experience, your head for strategy, your strength with relationships and your eye for opportunity. In return we offer an unmatched place to grow and develop your career among a richly diverse group of businesses driven by the power and stability of a leading health care organization. Come help us heal and strengthen the health care system as you do your life's best work.(sm)

The Investigations Consultant will be responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. This individual will utilize claims data, medical coding guidelines and their keen eye to identify abhorrent medical billing practices and patterns. They will be responsible to conduct investigations which may include field work to perform interviews and obtain medical records/ and other relevant documentation, The Investigations Consultant will also act as subject matter expert in researching and communicating their findings both orally and in writing and will be responsible to report any illegal activities in accordance with all applicable laws.

Primary Responsibilities
SIU Principal Investigator reports directly to the SIU Director. The primary responsibility of the Principal Investigator, under the direction of the SIU Manager, is to investigate the most complex cases of fraud, waste and abuse. The Principal Investigator’s principal responsibilities include:

  • Detecting fraudulent activity by members, providers, employees and other parties against the company and deciding the most effective and efficient method of investigation
  • Maintaining accurate, current and thorough case information in the SIU Case Tracking Database
  • Securing documentation, either internally or externally, and preparing summaries of the findings from the documentation
  • Documenting the evidence and drawing conclusions based on the investigative findings and preparing summaries of the investigative findings and case outcome
  • Representing the Company in conducting settlement negotiations
  • Gathering objective evidence in support of investigation outcomes
  • Collecting, collating, analyzing and interpreting data, both internally and externally, relating to fraud, waste and abuse referrals
  • Controlling and maintaining Company and departmental data to ensure confidentiality in accordance with the Data Release Governance Program
  • Reporting suspected fraud, waste and abuse to appropriate federal or state government regulators
  • Leading special projects
  • Preparing reports of SIU activity to assist the SIU Manager in presentation of final reports to the Board of Directors, the state and regulatory agencies, the health plans or UHC Senior Management
  • Assisting the SIU Manager in execution of the Manager’s responsibilities in the Manager’s absence
  • Attending at least 9 hours of continuing anti-fraud training annually

Required Qualifications

  • Undergraduate degree in the area of Criminal Justice, Business, or related field or equivalent work experience
  • 5+ years of experience working in a government, legal, health care, managed care and/or health insurance environment in a regulatory, privacy, compliance, or investigations role
  • An intermediate or better efficiency of knowledge with Local, State & Federal laws and regulations pertaining to healthcare fraud
  • Intermediate level of proficiency in MS Excel and MS Word
  • Must be willing and able to travel up to 25% within the state of FL
  • Must live within the vicinity of this specific career opportunity

Preferred Requirements

  • Experience within a healthcare Special Investigations Unit
  • Knowledge of medical terminology
  • Knowledge of medical coding (CPT,HCPCS,ICD-9,ICD-10)
  • Detail oriented with excellent organizational and analytical skills
  • CPC, AHFI or CFE

Every day, we work to make communities healthier. It's the promise that is at the core of who we are. And our employees' expertise makes all the difference in achieving our goal. Join our elite team today and start doing your life's best work.(sm)

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 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)

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: Investigations, Accredited Healthcare Fraud Investigator (AHFI) , Certified Fraud Examiner (CFE) , Certified Professional Coder (CPC), Medical, Local, State & Federal laws and regulations, law enforcement investigation, insurance claims, Investigate, Miramar, FL

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