Senior Investigator - Dental

About the position At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The Senior Investigator reports directly to the Manager of Investigations. The Senior Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. The Senior Investigator will utilize claims data, applicable guidelines and other sources of information to identify aberrant billing practices and patterns. The Senior Investigator position will be designated to work all fraud and abuse investigations related to the Texas Children’s Medicaid and Texas Children’s Health Insurance CHIP dental programs. The Senior Investigator is responsible to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: Investigate medium to highly complex cases of fraud, waste and abuse Detect fraudulent activity by members, providers, employees and other parties against the Company Develop and deploy the most effective and efficient investigative strategy for each investigation Maintain accurate, current and thorough case information in the Special Investigations Unit’s (SIU’s) case tracking system Collect and secure documentation or evidence and prepare summaries of the findings Participate in settlement negotiations and/or produce investigative materials in support of the latter Research, query, analyze and interpret data pertaining to dental claims and fraud, waste and abuse of dental claims Collect, collate, analyze and interpret data relating to fraud, waste and abuse referrals Ensure compliance of applicable federal/state regulations or contractual obligations Report suspected fraud, waste and abuse to appropriate federal or state government regulators Comply with goals, policies, procedures and strategic plans as delegated by SIU leadership Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at work-groups or regulatory meetings 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.

Responsibilities

• Investigate medium to highly complex cases of fraud, waste and abuse
• Detect fraudulent activity by members, providers, employees and other parties against the Company
• Develop and deploy the most effective and efficient investigative strategy for each investigation
• Maintain accurate, current and thorough case information in the Special Investigations Unit’s (SIU’s) case tracking system
• Collect and secure documentation or evidence and prepare summaries of the findings
• Participate in settlement negotiations and/or produce investigative materials in support of the latter
• Research, query, analyze and interpret data pertaining to dental claims and fraud, waste and abuse of dental claims
• Collect, collate, analyze and interpret data relating to fraud, waste and abuse referrals
• Ensure compliance of applicable federal/state regulations or contractual obligations
• Report suspected fraud, waste and abuse to appropriate federal or state government regulators
• Comply with goals, policies, procedures and strategic plans as delegated by SIU leadership
• Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at work-groups or regulatory meetings

Requirements

• Bachelor’s degree or Associates degree plus 2+ years of equivalent work experience with healthcare related employment
• Hold the designation of Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) OR have at least 3 years of prior Medicaid/CHIP fraud, waste and abuse investigatory experience
• Intermediate level of proficiency in Microsoft Excel and Word
• Intermediate level of knowledge and experience in health care (including dental) fraud, waste and abuse (FWA) investigations
• Intermediate level of knowledge with local, state/federal laws and regulations pertaining to healthcare fraud, waste and abuse (FWA)
• Ability to travel up to 25%25

Nice-to-haves

• Specialized knowledge/training in healthcare FWA investigations
• Active affiliation with National Health Care Anti-Fraud Association (NHCAA)
• Accredited Health Care Fraud Investigator (AHFI)
• Licensed Dentist
• Certified Fraud Examiner (CFE)
• Certified Professional Coder (CPC)
• Certified Dental Coder (CDC)
• Registered Dental Hygienist
• Ability to develop goals and objectives, track progress and adapt to changing priorities
• Average skills in data manipulation
• Average skills in developing investigative strategies
• Ability to participate in legal proceedings, arbitrations, depositions, etc.
• Ability to develop goals and objectives, track progress and adapt to changing priorities

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