UCare

Healthcare Fraud Investigator

Employer
UCare
Location
Minneapolis, Minnesota
Posted
Aug 11, 2020
Closes
Sep 17, 2020
Ref
2055
Category
Healthcare
Employment Status
Full Time
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.

Rewards

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.

www.ucare.org/careers/

EOE/AA

ABOUT UCARE

UCare offers Medicare, Medicaid, Individual and Family health plans - powered by the hardest working people in the industry. Our people powered teams de-complicate, advocate and always go the extra mile to help our members. We serve with integrity, compassion and commitment to do right by members, providers and government partners. Above all, we come to work excited to provide members a path for the best health of their lives.

WORKING AT UCARE

Working at UCare is more than 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. Employees join UCare and stay because of the opportunity to have a purpose-driven job.

Our strong culture has established UCare as a Star Tribune Top 150 Workplace for 11 consecutive years since the awards program began. It's a culture that embraces innovative ideas, strategic partnerships, and exemplary customer and provider experiences. Working at UCare is being a part of a people powered team dedicated to making a real difference in the lives of our members and communities.

HEALTHCARE FRAUD INVESTIGATOR

Position Description

This position is responsible to detect and investigate alleged or suspected fraud, waste, and abuse (FWA) by network providers or enrolled members. Conduct data mining, analytics 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, and/or referrals to state and federal enforcement agencies. Prepare FWA data reports for submission to regulators. Provide testimony on behalf of UCare in both civil and criminal proceedings.

• Collaborate with manager to investigate allegations of FWA.

• Collect and analyze case evidence to include, but not limited to: medical records, business records, financial records, and claims data. 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 overpayments. Make referral of case findings to appropriate law enforcement and/or regulators.

• Conduct interviews of witnesses or targets and perform field work to include provider site visits and surveillance.

• Support internal compliance reviews as appropriate, including accurate tracking of case information and timely reporting as needed for external audits and regulatory oversight.

• 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 analytics using available tools. This includes 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.

• Represent UCare as a witness in court actions as required, and in affidavits as approved by Legal.

• Participate in preparing and submitting required FWA reporting to regulatory agencies.

• Respond to data requests submitted by external parties.

• Other projects and duties as assigned.

Education

Bachelor's degree; demonstrated experience may be considered in lieu of degree.

Required Experience

One year of experience performing investigations, preferably in health care or fraud. Knowledge of medical terminology. Demonstrated competence using data to perform investigations, including intermediate skill level with Excel and/or Access.

Preferred Experience

Experience working in a SIU within the health care industry. Knowledge of Medicare and Medicaid.

THE UCARE DIFFERENCE

The UCare difference is our people power - employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, 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.

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