Clinical Investigator

About this role

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities

Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting

Growing together. This process works on identifying Fraud, Waste and Abuse between medical records and billed services for complex and high value claims by identifying Up-coding, Unbundling, Duplication, and Misrepresentation of services. They approve or deny claims and Identify provider aberrant behavior patterns

The associates prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT or diagnosis codes, CMS guideline along with referring to client specific guidelines and member policies. Fraud is intentionally misrepresenting or concealing facts to obtain something of value. The complete definition has three primary components: Intentional dishonest action or misrepresentation of fact Committed by a person or entity With knowledge that dishonest action or misrepresentation could result in an inappropriate gain or benefit This definition applies to all persons and all entities

However, there are special rules around intentional misrepresentations to Government programs such as Medicare and Medicaid, or TRICARE. Waste includes inaccurate payments for services, such as unintentional duplicate payments, and can include inappropriate utilization and/or inefficient use of resources. Abuse includes any practice that results in the provision of services that: Are not medically necessary Do not meet professionally recognized standards for health care Are not f

Apply for this role on UnitedHealth Group’s official careers site.