Position Description:Energize your career with one of Healthcare's fastest growing companies. You dream of a great career with a great company - where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it's a dream that definitely can come true. Already one of the world's leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up. This opportunity is with one of our most exciting business areas: Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 17 leader. Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation and Performance. Primary Responsibilities:Facilitates case load balancing and flag management opportunitiesSupports adherence to case review turnaround of region and acts as SME / Mentor for regionEnsures own case load completed within standard turnaround expectationsCase assignment completed in timely manner and/or inventoryProvide support to new hires through on - boarding processAssist with mentoring and / or side by sidesIdentify training needs and development for new hires and existing staffComplete a values based presentationFacilitate an overview from another department to increase awareness of operational partnersExamine, assess, and document business operations and procedures to ensure data integrity, data security and process optimizationInvestigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entitiesInvestigate and pursue recoveries and payables on subrogation claims and file managementInitiate phone calls to members, providers, and other insurance companies to gather coordination of benefits informationProcess 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 expertiseGenerally, work is self - directed and not prescribedWorks with less structured, more complex issuesServes as a resource to others
Requirements:Associate's Degree (or higher) in the area of Criminal Justice OR a High School Diploma / GED with 5+ years of experience working in a FWA / SIU or Fraud investigations role for New Jersey / New York location)2+ years of experience within the health insurance claims industry2+ years of experience working on at least one of the following claims platforms: UNET, COSMOS, or FACETS, needs working knowledge of the claims processIntermediate level of knowledge with Local, State & Federal laws and regulations pertaining to insuranceIntermediate proficiency in Microsoft Excel (pivot tables and macros) and Microsoft Word (documents)Ability to travel up to 10% of the timeAssets:Undergraduate Degree (or higher)2+ years of experience working with law enforcement or legal entitiesKnowledge of benefit structure for all lines of business (Medicaid, Medicare)Experience in Six Sigma or Lean methodologies and toolsProfessional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similarCareers 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: fraud investigation, healthcare claims, federal laws, regulations, coaching, mentoring, United Healthcare, Optum
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.