As a key member of UHCPI Fraud Prevention, you will be part of UnitedHealth Group's mission of making health care affordable for everyone. As a Senior Business Analyst, you will be responsible for communication with constituents who report healthcare concerns and various allegations of health care fraud through the External Fraud Hotline. This position requires the business analyst to quickly review all allegations, triage the allegation to assess for validity and determine the best course of handling.
- Review all fraud hotline tips and analyze data for viable allegations of health care fraud
- Responsible for communication back to the reporter to obtain additional information as needed to effectively address allegations of fraud
- Work with internal investigative areas of the company to ensure timely progression and resolution of all fraud tips received through the hotline
- Collaborate with other areas of the organization to address any non - FWA concerns that are reported via the hotline such as Privacy, Eligibility, Quality of Care, Coordination of Benefits, Claim and Billing disputes, Subrogation, etc.
- Identify any patterns or trends that could result in the creation of claim edits or new reimbursement and / or medical policies
- Handle escalated executive level issues related to healthcare fraud which may have high visibility to senior leaders and executives
- Prior experience with identifying healthcare fraud, preferably in an investigative role.
- Bachelor’s degree required or equivalent combination of education and work experience in relevant field such as Criminal Justice, Business, Finance, Health Administration or Healthcare
- Working knowledge of Medicare, Medicaid and Commercial Insurance products and benefits
- Working knowledge of internal claim systems (UNET, COSMOS, CSP, NICE, Oxford), review of internal clinical and reimbursement policies and various systems edits and processes (Encoder Pro, iCUE, iSET)
- Proficient with PC based software programs and automated database management systems required (Excel, Access, Word, PowerPoint, Outlook, SharePoint)
- 5+ years of Health Care Fraud investigative experience or AHFI, CFE certification
- Clinical Experience in the health care field i.e. nursing, therapy, social work
- Medical Coding certification
- Ability to communicate in writing and verbally with members, providers, external reporters, internal partners and key stakeholders to gather necessary information to address allegation of fraud
- Able to prioritize and work in a fast - paced, time sensitive environment
- Must be detail oriented and able to problem solve, prioritize multiple responsibilities and have the ability to identify and research conflicting and / or inaccurate data
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)
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
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: Senior Analyst, Fraud Prevention, UnitedHealthcare, UHC, PI, Payment Integrity, Telecommute, Telecommuter, Telecommuting, Work from Home, Work at home, Fraud Hotline, Healthcare Fraud, Minneapolis, MN