Investigator Senior

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 200 Workplace for 16 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.

INVESTIGATOR SENIOR

The current hiring base salary range for this role is:

$75,389.00/year – $84,812.40/year 

UCare anticipates paying within the above-references salary range for this position. The actual base salary offer for this position will be determined by a variety of components including but not limited to work experience, education, certifications, location of the role, internal equity, and other relevant factors.

LOCATION: Minneapolis, MN (Work from Home, Office for Your Day)

Position Description

As an Investigator Senior, you will be responsible to detect, prevent, investigate, and correct alleged or suspected fraud, waste and abuse (FWA) by providers or 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, corrective action(s), and/or referral to state and federal enforcement agencies. Represent UCare as a witness in court actions as required. Prepare data reports for submission to regulators. Act as back-up to SIU leadership, as needed.

• Collaborate with SIU leadership to investigate allegations of fraud, waste and abuse. 

• Collect, review and analyze case evidence such as patient records, 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 overpayments. Make referral of findings to law enforcement or regulators as appropriate and as directed by SIU leadership. 

• Conduct interviews of witnesses or targets and perform field work including provider site visits and surveillance, as needed. 

• Manage large and/or complex investigations, providing guidance to investigative and operational team members. 

• Mentoring less senior SIU staff in investigative and interview techniques, case development, and report writing. 

• Represent UCare as a witness in court actions as required, under the direction of the SIU leadership. 

• 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 to SIU leadership, as needed. 

• 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 intermediate to advance functionality in Excel, performing manipulation, sorting, analysis, application and development of formulas, summarization and presentation of data in an understandable and reliable format. Develop query logic or algorithms for identification of aberrancies. 

• Consult with legal, law enforcement and regulators regarding and respond to Requests for Information, as assigned.