Payment integrity Analyst - Remote

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Optum Serve helps federal agencies and communities across the nation tackle some of the biggest challenges in health care. With trillions of dollars spent on health care annually, in the United States, the potential for abuse is staggering. Even worse, the lives of millions of patients hang in the balance.

Join Optum Serve as a Payment Integrity (PI) Analyst where you will be responsible for identification, investigation and prevention of healthcare Fraud, Waste, and Abuse (FWA) The Sr. PI Analyst will utilize claims data, applicable policy and guidelines, and other sources of information to identify aberrant billing practices and patterns. The PI Analyst is responsible for conducting investigations which will require the gathering of all relevant facts, records and/or other relevant documentation.

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Validate and investigate referrals of fraud, waste, and abuse (FWA)
• Detect fraudulent activity by beneficiaries, providers, and other parties against the government contracts
• Develop and deploy the most effective and efficient investigative strategy for each investigation
• Maintain accurate, current, and thorough case information in the case tracking system
• Collect and secure documentation or evidence and prepare summaries of the findings
• Collect, collate, analyze, and interpret data relating to fraud, waste, and abuse referrals
• Document and report financial impact of investigation outcomes
• Support and gather responses to subpoenas received from federal law enforcement and other legal entities
• Ensure compliance of applicable federal/state regulations or contractual obligations
• Collaborate with internal business partners to help drive the investigation process
• Collaborate with a variety of external sources to identify current and emerging patterns and schemes related to fraud, waste, and abuse (e.g., NHCAA, law enforcement)
• Participate in any audits requested by the government
• Comply with goals, policies, procedures, and strategic plans as delegated by leadership
• Collaborate with federal partners, to include attendance at workgroups, regulatory meetings, requests for information, or case discussions
• Communicate effectively, including written and verbal forms of communication
• Manage and prioritize assigned caseloads to meet required turnaround time

• 3+ years of experience in health care fraud, waste, and abuse (FWA)
• 3+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity
• Experience gathering information for and responding to subpoenas
• Experience with federal FWA programs and contracts
• Demonstrated knowledge of applicable medical terminology and coding guidelines (e.g., CPT, HCPCS, ICD-9, ICD-10)
• Demonstrated understanding of how claims are processed and adjudicated
• Demonstrated understanding and navigation of claims processing platforms
• Proven critical thinker

• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• 3+ years of experience developing investigative strategies
• Advanced knowledge and experience of Statistical Analysis
• Proficiency in performing financial and statistical analysis including statistical calculation and interpretation