Opportunity is here


Director of Program Integrity - Remote - 2225503



Boston, MA, USA
Posted on Friday, May 31, 2024

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

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

Primary Responsibilities:

  • Direct provider compliance and payment integrity audit reviews based on applicable standards, state/federal regulations, customer requests, internal requests, or project assignments
  • Centrally manage full spectrum of audit operations, from audit strategic planning to coordinating recovery of financial penalties
  • Direct audit program development in a fast-paced, cross-functional framework in collaboration with client leaders, as well as internal Optum technical, operations, and production teams
  • Develop claim analyses (algorithms) to identify programmatic and claim processing system vulnerabilities and opportunities to maximize financial recovery for client(s)
  • Apply data mining and analysis techniques to identify fraud trends and profile providers for possible investigation
  • Identify quality improvement and training opportunities and work cross-functionally to develop interventions and recommendations
  • Develop or update work plans, job aids, and policies and procedures
  • Work cross-functionally evaluating process and procedures, making recommendations or clarifying information to assist in closing gaps that are identified or meeting customer expectations
  • Lead, manage, and actively participate in various meetings both with internal and external stakeholders
  • Educate, motivate, and/or influence others (e.g., leadership, other stakeholders, including those for whom there is no direct line of authority) to understand the overall scope, overcome potential barriers, and engage in and commit to the process

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Professional accreditation as either an Accredited Healthcare Fraud Investigator (AHFI) or a Certified Fraud Examiner (CFE), or other comparable certifications
  • 5+ years of experience in developing analytics specifically for detecting fraud, waste, and abuse
  • 5+ years of management experience with demonstrated ability to navigate a team and business sponsors through a level of ambiguity including algorithm development, specifications programming, data mining, and process improvement
  • 2+ years of experience in Medicaid LTSS programs
  • Experience in using, directing, and managing automated data mining tools for program integrity
  • Ability to travel 10% of the time

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for this role is $122,100 to $234,700 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.