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Investigator - Kingston, NY

UnitedHealth Group

Kingston, NY
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Job Details

735363 Investigator Kingston NY

Investigator - Kingston, NY (735363)

Position Description

Position Description:

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 Investigator will be responsible for investigating and resolving instances of healthcare fraud and / or abusive conduct by the medical profession, insured members or the broker community. This individual will be utilizing information from claims data analysis, plan members, employee's conduct confidential investigations and document relevant findings. They will report any illegal activities in accordance with all laws and regulations. The Investigator may also conduct onsite provider claim and / or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. They will act as a subject matter expert with identifying, communicating and recovering losses as deemed appropriate. Where applicable, they will provide testimonials regarding the investigation.  
Primary Responsibilities:
  • Performing queries on relevant systems (e.g., claims systems; data warehouse) in order to obtain relevant information
  • Validating claims data against information from claims processing systems to ensure that the data is accurate using Excel and Access software
  • Analyze claims data against applicable internal and external policies, laws, and regulations to determine potential issues (e.g., billing anomalies; over - payments; claims processing system issues)
  • Review paid claims to identify potential claims paid in excess of correct reimbursement
  • Review history of related claims to pull in and understand additional claims - related information
  • Interpret and / or integrate data from multiple sources to identify error trends and root causes of claims over - payment (e.g., duplicate payment; coordination of benefits; contract set - up / interpretation; potential fraud, waste, or abuse)
  • Validate results of claims analysis resulting from investigation to ensure accuracy and quality
  • Determine financial implications of potential courses of actions
  • Demonstrate knowledge of healthcare coding practices (e.g., CPT's; HCPCS; DRG; ICD - 10)
  • Demonstrate understanding of how to read and interpret supporting documentation including financial and medical records obtained in auditing processes.
  • Demonstrate understanding of relevant end - to - end claims adjudication processes.
  • Demonstrate exceptional written and verbal communication skills
Required Qualifications:
  • Associate’s Degree (or higher) in Criminal Justice or a related field
  • 5+ years of Insurance Claims Investigation or professional investigation experience with law enforcement agencies and / or 7+ years of professional investigation experience involving economic or insurance related matters
  • Intermediate level skills with Microsoft Excel, Microsoft Word, and Microsoft Access
Preferred Qualifications:
  • Bachelor’s Degree (or higher) in Criminal Justice or a related field
  • Advanced level skills with Microsoft Excel, Microsoft Word, and Microsoft Access
  • Experience with the group health business preferred, particularly within claims processing
  • An intermediate level of knowledge with Local, State, & Federal laws and regulations pertaining to insurance
Soft Skills:
  • Experience in a position requiring excellent verbal and written communication skills.
Careers at UnitedHealthcare Employer & Individual. We all want to make a difference with the work we do. Sometimes we're presented with an opportunity to make a difference on a scale we couldn't imagine. Here, you get that opportunity every day. As a member of one of our elite teams, you'll provide the ideas and solutions that help nearly 25 million customers live healthier lives. You'll help write the next chapter in the history of health care. And you'll find a wealth of open doors and career paths that will take you as far as you want to go. Go further. This is 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.
Keywords: UnitedHealth Group, Kingston, Investigator, Claims Investigation, Insurance Claims, Claims Analysis

Job Details

  • Contest Number735363
  • Job TitleInvestigator - Kingston, NY
  • Job FamilyRegulatory and Compliance
  • Business SegmentEmployer and Individual

Job Location Information

  • Kingston, NY
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionNo
  • Overtime StatusExempt

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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