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 Principal Investigator reports directly to the Manager of Investigations. The Principal Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste, and abuse. The Principal Investigator will utilize claims data, applicable guidelines, and other sources of information to identify aberrant billing practices and patterns. The Principal Investigator is responsible to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.

If you reside in KY you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Investigate 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 later
• 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 workgroups or regulatory meetings
• Communicate effectively, to include written and verbal forms of communication
• Develop goals and objectives, track progress and adapt to changing priorities

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:

• Bachelor's degree or higher
• Demonstrated advanced level of knowledge in health care fraud, waste and abuse (FWA) or 5+ years of experience, 3 of which must be specific to Medicaid Fraud
• Demonstrated advanced level of knowledge in state or federal regulatory FWA requirements or 5+ years of experience
• Demonstrated advanced level of knowledge analyzing data to identify fraud, waste and abuse trends or 5+ years of experience
• Demonstrated advanced level of proficiency in Microsoft Excel and Word or 5+ years of experience
• Proven ability to participate in legal proceedings, arbitration, and depositions at the direction of management
• Willing or ability to travel up to 25% as needed throughout the state of KY

Preferred Qualifications:

• Demonstrated intermediate level of knowledge in health care policies, procedures, and documentation standards or 5+ years of experience
• Demonstrated intermediate level of skills in developing investigative strategies or 5+ years of experience
• Specialized knowledge/training in healthcare FWA investigations
• Active affiliations:
  • National Health Care Anti-Fraud Association (NHCAA)
  • Accredited Health Care Fraud Investigator (AHFI)
  • Certified Fraud Examiner (CFE)
  • Certified Professional Coder (CPC)
  • Medical Laboratory Technician (MLT)
• Advanced knowledge and experience in any of the following:
  • Statistical Analysis Software (SAS)
  • R
  • Python
  • Tableau
  • Toad
  • Structured Query Language (SQL)
  • Visual Basic for Applications (VBA)
  • Alteryx
• Advanced knowledge and experience in any of the following:
  • Statistical Analysis
  • Regression Analysis
  • Linear Analysis
  • Market-basket Analysis

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

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.