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 & Performance.
Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work.
The SIU Clinical Investigator will work with a team on researching issues to determine feasibility of reducing medical costs through prospective solutions of claim system processes and claim business rules.
- Review suspect claim submissions to identify suspect or aberrant billing patterns
- The SIU Clinical Investigator is responsible to pull daily inventory and assign tasks to team members meeting timeline requirements
- Request Medical Records
- Complete Comprehensive Investigative Reports
- Communicate and identify new aberrant claim activity to other related departments
- Submit suspect providers for reporting, to the Department of Insurance or appropriate Medical Board
- Identify new suspect providers
- Identify opportunities to inactivate, or modify current flags, or edits
- The SIU Clinical Investigator is responsible for the daily assessment of suspect claims that edit to Optum for review
- Claims and the requests for documentation to support or disprove an allegation of abusive billing patterns must be handled within State and Department of Insurance compliance time frames
- Meet required metrics and quality
- Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance
- Identifies and resolves operational problems using defined processes, expertise and judgment
- Research and respond to escalated inquiries or requests from management or internal sources
- Training of new employees
- Act as a resource and mentor to the team
- Conduct individual QA during ramp-up of new investigators
- Handle QA rebuttals to the QA team
- Participate in audits and follow-up action, as required
- Provide recommendation & help update departmental documentation (SOP’s, Job Aides, PnP’s, etc.