Healthcare Claims Investigator - San Juan, PR,
Optum, San Juan, San Juan, United States
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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale.
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, employees conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. They may conduct onsite provider claim and/or clinical audits to gather and analyze all necessary information and documents related to the investigation. They identify, communicate and recover losses as deemed appropriate. Where applicable, testimony regarding the investigation may be required. They 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 PROFICIENT 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, PowerPoint, Word, Outlook and Excel
Ability to work (40 hours/week) Monday‑Friday. Flexible to work any of our 8‑hour shift schedules during our normal business hours of 6:00 am to 6:00 pm EST. It may be necessary, given the business need, to occasionally work mandatory overtime, holidays or weekends
English proficiency
Preferred Qualifications
1+ years of experience in Appeals and Grievances
Experience with one or more of the following:
Provider demographic information
Insurance billing practices
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)
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.
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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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, employees conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. They may conduct onsite provider claim and/or clinical audits to gather and analyze all necessary information and documents related to the investigation. They identify, communicate and recover losses as deemed appropriate. Where applicable, testimony regarding the investigation may be required. They 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 PROFICIENT 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, PowerPoint, Word, Outlook and Excel
Ability to work (40 hours/week) Monday‑Friday. Flexible to work any of our 8‑hour shift schedules during our normal business hours of 6:00 am to 6:00 pm EST. It may be necessary, given the business need, to occasionally work mandatory overtime, holidays or weekends
English proficiency
Preferred Qualifications
1+ years of experience in Appeals and Grievances
Experience with one or more of the following:
Provider demographic information
Insurance billing practices
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)
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.
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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