Associate Director of Business Analyst

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.

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.

• 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

• 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