SIU -Fraud Investigator Senior
Health Care that Starts with You!
Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota's leading health plans. We provide more than 225,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs. UCare is growing in size, membership, products, geographic coverage, and employees. We're an organization that's going places. Be part of a team that cares about you, be part of UCare.
ABOUT UCAREAt UCare, we deliver high-quality health coverage and services to help members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities. WORKING AT UCAREWorking at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other. Our values of integrity, community, quality, flexibility, and respect permeate every aspect of our organization - from who we are and how we act, to what we do and how we do it. We owe our continued success to our employees who proudly embody our mission and values in everything they do. SIU - FRAUD INVESTIGATOR SENIOR Position DescriptionThis position is responsible to detect and investigate alleged or suspected fraud, waste and abuse (FWA) by network providers or enrolled members. Conduct data mining, analysis and auditing/monitoring activities. Suggest integrity measures or program controls and engage in FWA prevention efforts. Prepare investigative reports for internal recovery efforts, network action, or referral to state and federal enforcement agencies. Represent UCare as a witness in court actions as required, and in affidavits as approved by Legal. Prepare FWA data reports for submission to regulators. Act as back-up final approver for case/lead closures. Specific duties and responsibilities include: Collaborate with manager, investigate allegations of fraud, waste and abuse. Collect, review and analyze case evidence such as patient charts, business records, financial ledgers, and claims data spreadsheets. Perform analysis of applicable regulations, contracts and policy manuals to determine whether violations exist. Write investigative reports summarizing evidence, investigative activities, and findings. This includes compiling and organizing accurate case file documentation and calculation of over-payments. Make referral of findings to law enforcement or regulators as appropriate and as directed by manager. Conduct interviews of witnesses or targets, and perform field work including provider site visits and surveillance, as needed. Project manage large and/or complex investigations, providing guidance to investigative and operational team members. Represent UCare as a witness in court actions as required, and in affidavits as approved by Legal, under the direction of manager. Support internal compliance reviews as appropriate, including accurate tracking of case information and timely reporting as needed for external audits and regulatory oversight. Act as back-up approver for case/lead closures. Serve as a resource for departments to research and resolve integrity inquiries and assist in identification of improvements to internal practices that may reduce or prevent FWA. Conduct data mining and data analysis using available tools and internal data warehouse. This includes basic to intermediate functionality in Excel or similar software, performing manipulation, sorting, analysis, summarization and presentation of data in an understandable and reliable format. Develop query logic or algorithms for identification of aberrancies. Serve a mentor and coach for less experienced investigators. Consult with legal, law enforcement and regulators regarding and respond to Requests for Information. Other projects and duties as assigned.EducationBachelor's degree in the area of Criminal Justice or related field; equivalent experience may be considered in lieu of degree.Required ExperienceFive years of experience performing health care fraud investigations or experience performing other types of investigations. Working knowledge of medical and pharmaceutical terminology. Demonstrated competence using data to perform investigations, including intermediate to advance skill level with Excel and/or Access or audit tools. Experience performing complex investigation oversight. Basic understanding of state and federal laws and regulations pertaining to insurance. Preferred ExperienceExperience in performing healthcare fraud investigations. Knowledge of Medicare and/or Medicaid. Project management experience. Experience as a witness in court action or proceedings. Understanding of provider network or contract management.THE UCARE DIFFERENCEUCare is proud to be a recognized Star Tribune Top Workplace for the 7th consecutive year. As a part of our collaborative team, you'll experience the rewards that come with helping others and seeing the positive results of your hard work. We value and respect each individual's ideas and contributions, and give you the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, a myriad of volunteer activities, and a number of other rewards. If you're looking for a welcoming environment that celebrates what you have to offer, helps you build on your strengths, and gives you the opportunity to truly make a difference, we invite you to apply. As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.
Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You'll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis just minutes from major freeways and retail centers.
At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.