Healthcare Claims Investigator - San Juan, PR

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Employees are responsible for triaging, investigating and resolving instances of healthcare fraud and/or abusive conduct by medical professionals. Using information from tips and complaints from plan members, the medical community and law enforcement, employee's conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. May conduct onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. Identify, communicate and recover losses as deemed appropriate. Where applicable, testimony regarding the investigation may be required. May also complete root cause analysis.

Primary Responsibilities:

• Assist the prospective team with special projects and reporting
• Initiate phone calls to members, providers, and other insurance companies to gather information
• Investigate and/or resolve all types of claims for health plans, commercial customers, and government entities
• Triage claims data to send for medical coding review
• Collaborate with clinical coding consultants for purposes of educating and communicating to provider
• Review medical records to gather relevant facts to drive investigations and communications
• Conduct data mining and analysis for potential flags
• Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders (referrals and OP)
• Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
• Utilize appropriate systems to monitor and document status of investigations
• Monitor investigation status throughout the process
• Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA
• Use pertinent data and facts to identify and solve a range of problems within area of expertise
• Generally, work is self - directed and not prescribed
• Work with less structured, more complex issues
• Serve as a resource to others
• ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION *

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:

• 2+ years of experience in Claims processing
• Experience using claims platforms such as UNET, Pulse, NICE, Facets, Diamond, etc.
• Working experience with Microsoft Tools: Microsoft Teams (join meetings and trainings), Microsoft Power Point (prepare presentations), Microsoft Word (creating memos, writing), Microsoft Outlook (setting calendar appointments, email) and Microsoft Excel (creating spreadsheets, filtering, navigating reports)
• Ability to work (40 hours/week) Monday - Friday. Flexible to work any of our 8-hour shift schedules during our normal business hours of (6:00am to 6:00pm EST). It may be necessary, given the business need, to occasionally work mandatory overtime, holidays or weekends
• English proficiency
• Driver's License and access to reliable transportation

Preferred Qualifications:

• Organization affiliation and/or certification:

• Association of Certified Fraud Examiners (ACFE)

• Certified Fraud Examiner (CFE)

• National Health Care Anti-Fraud Association (NHCAA)

• Accredited Healthcare Fraud Investigator (AHFI)

• International Association of Special Investigation Units (IASIU)

• Certified Insurance Fraud Investigator (CIFI)

• Certified Insurance Fraud Analyst (CIFA)

• Certified Insurance Fraud Representative (CIFR)

• 1+ yrs of experience in Appeals and Grievances

• Provider demographic information

• Insurance billing practices

• Coding experience

• Managed care experience

• Claims processing experience

• Medical record familiarity

• Experience in healthcare claims investigations

• Experience in lean and/or six sigma methodology

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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.