Associate Director of Business Analyst

UnitedHealth Group

(Frederick, Maryland)
Full Time
Job Posting Details
About UnitedHealth Group
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.
Summary
The Associate Director is an important contributor to the UHC Anti-Fraud Program and is responsible for identifying, preventing and investigating the fraud, waste and abuse (FWA) of medical and pharmacy benefits.
Responsibilities
* Analyzing and monitoring claims for FWA relating to government programs and / or UHC health plans * Performing comprehensive research and analysis of claims data and related information, and applying detailed knowledge of medical and pharmacy policy to identify fraudulent or abusive billing activity * Conducting onsite audits of physician offices, long-term care facilities, and pharmacies to inspect their facilities, assess their compliance with regulatory requirements, and review provider / clinical records and itemized bills for accuracy and completeness * Identifying and documenting fraudulent or erroneous activities discovered during an audit, to include any false claims and / or claim overpayments * Conducting detailed investigations and developing cases to the level of a probable cause showing * Working collaboratively with regulatory and / or law enforcement agencies to develop FWA cases, to include active participation in healthcare fraud task forces * Supporting legal proceedings (civil and criminal), to include testifying before the grand jury or in court * Work effectively with the Advanced Analytics Team and various business segment analysts to develop fraud theories and assess case leads based on the analysis of claims data * Demonstrate a sound understanding of what fraud is and its application to the healthcare insurance industry, to include Medicare, Medicaid, and Commercial healthcare programs * Work collaboratively with external entities, to include outside vendors, legal counsel and state and / or federal law enforcement and / or regulatory agencies * Demonstrate a strong understanding of healthcare insurance claim forms, billing / coding practices and terminology, and medical record reviews * Assess large volumes of data and other information to reach sound fraud determinations
Ideal Candidate
* Undergraduate degree or equivalent experience * 6+ years of experience in the health care industry, preferably in an auditing or SIU role * 5+ years of supervisory experience * 5+ years of experience performing comprehensive research and analysis of claims data, and applying detailed knowledge of medical and pharmacy policy to identify fraudulent or abusive billing activity * 5+ years of experience conducting internal and on-site audits of provider records, clinical records, and itemized bills so as to ensure appropriateness of billing practices and application of medical policy; * 5+ years of experience identifying and documenting fraudulent or erroneous activity during an audit * An intermediate level of proficiency in performing financial analysis, to include statistical calculations and interpretations * Excellent written and verbal communication skills * Excellent time management and prioritization skills to consistently meet stated deadlines * An intermediate level of proficiency with Microsoft Excel, Word and Access **Preferred Requirements:** * Clinical and / or pharmacy benefit management experience * Coding and / or billing experience relating to medical and pharmacy benefits * 4+ years of experience with claims processing systems such as UNET, COSMOS, Facets, Diamond, etc * 4+ years of experience with contracting applications (diCarta, Contract Manager, Purchasing Calendar and CCI Submission Databases) and guidelines

Questions

Answered by on
This question has not been answered
Answered by on

There are no answered questions, sign up or login to ask a question

Want to see jobs that are matched to you?

DreamHire recommends you jobs that fit your
skills, experiences, career goals, and more.