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. Employees are responsible for triaging, investigating and resolving potential instances of healthcare fraud and/or abusive conduct by medical professionals or providers. Using information from tips, complaints, external intelligence or behavior data, the medical community and law enforcement, employee's conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. May request onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. Identify, communicate and recover losses as deemed appropriate. These investigations may include participation in telephone calls or meetings with providers, members, clients, legal, compliance, and other investigative areas and requires adherence to state and federal compliance policies, reimbursement policies, and contract compliance. Where applicable, testimony regarding the investigation may be required in a court of law. May also complete root cause analysis. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Gather and analyze data and information gathered to determine behavior and understand provider/scheme at issue - Utilize appropriate documentation and tracking controls in the case tracking system to ensure compliance and auditability requirements are met - Collaborate with clinical coding consultant to apply knowledge of coding guidelines to determine validity of aberrances (SIU only) - Gather all relevant facts to articulate behavior through an Investigation Summary and compliance package. Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders - Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA to ensure additional TIP submission - Perform member and provider interviews, and review medical documentation as needed - Answer inbound calls from members/providers and assist with various inquiries - Communicate with legal, Law Enforcement, clients and business partners as needed - Conduct provider onsite audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation 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: - 5+ years of experience in an investigative role working with healthcare claims, managed care and/or within a health insurance environment - 2+ years of experience working with law enforcement or legal entities or 3-5 years Investigative experience with fraud investigations - 1+ years of experience with behavioral health codes and service delivery - Intermediate level of proficiency in MS Excel (ability to use pivot tables, formulas, functions, etc.) - Intermediate level of proficiency in MS Word (ability to create/edit documents) Preferred Qualifications: - Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar - Bachelor’s degree, undergraduate degree in Criminal Justice or related field - Familiar with CPT code terminology - Experience with computer research - Experience with regulatory compliance - Experience with data analysis as it relates to financial recovery/settlements *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. 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. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. #RPO #GREEN

Our Medical Review Nurse Analyst is responsible for conducting clinical reviews of medical records to ensure compliance with regulatory and payer guidelines. This analyst ensures that providers are being reimbursed appropriately for services provided based on Medicare guidelines. This Medical Review Nurse Analyst reviews claims and delivers provider education on current billing and documentation requirements. Salary Range $68,000 - $70,000 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. Remote Work Location We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin How do I know this opportunity is right for me? If you: - Can perform detailed reviews of medical records and documentation to determine the medical necessity of services. - Would enjoy reviewing submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines. - Want to ensure Medicare providers are correctly reimbursed when documentation supports services rendered. - Have prepared written clinical summaries and determinations with clear rationale for approvals, denials, or modifications. - Would like to educate providers in accordance with the Targeted Probe and Educate (TPE) program. - Can monitor the progress of assigned providers and educate on current billing and documentation requirements. - Want to ensure compliance with federal and state regulations, CMS guidelines, and company policies. - Enjoy staying current on clinical guidelines, medical policy updates, and industry best practices. Minimum Qualifications - Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN). - Active RN license, applicable to state of practice in good standing. - 1 or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.). - Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely. - Strong attention to detail and organizational skills to manage multiple cases simultaneously. - Basic knowledge and understanding of medical/clinical review processes. - Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel. Preferred Qualifications - Experience working for a Medicare Administrative Contractor (MAC). - Familiarity with Medicare guidelines and reimbursement processes. - Experience with medical record review or utilization review. Remote Work Requirements - Wired (ethernet cable) internet connection from your router to your computer - High speed cable or fiber internet - Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net) - Please review Remote Worker FAQs for additional information Benefits - Remote work options available - Performance bonus and/or merit increase opportunities - 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately) - Competitive paid time off - Health insurance, dental insurance, and telehealth services start DAY 1 - Professional and Leadership Development Programs - Review additional benefits: (https://www.wpshealthsolutions.com/careers/) Who We Are WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready. Culture Drives Our Success WPS’ culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities. We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition. Sign up for Job Alerts FOLLOW US! Instagram LinkedIn Facebook WPS Health Blog This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services

Smartly is looking for a Quality Analyst to conduct functional and manual testing of creative ads across different browsers and platforms. The role involves collaborating with developers to optimize campaigns. Ideal candidates should have strong attention to detail, critical thinking, and adaptability in a fast-paced environment. As a Quality Analyst at Smartly, you will... - Conduct functional and manual testing procedures on HTML5 creative ads on different browsers and platform - Check and ensure the consistency of image and video assets - Review requirements, specifications and technical design documents to provide timely and meaningful feedback - Write comprehensive test cases and execute tests following standards and best practices - Responsible for the overall quality of the creative ads ensuring that it will look and work as designed - Create reports documenting revisions and other details - Report bugs and errors to solutions and development teams - Collaborate with the developers and other teams as needed - Provide optimization support on campaigns We're definitely looking for you, if you... - Are able to adapt quickly to fast-paced and dynamic work environments - Have excellent attention to details - Have good communication and critical thinking skills - Are a team player and must come with a positive working attitude - Have familiarity with cross-browsing tools (e.g. BrowserStack) - Doubleclick Studio experience is a plus - Basic knowledge on HTML5 - Are amenable to work on a shifting schedule and hybrid work set up #LI-HYBRID About SmartlySmartly is the AI-powered advertising technology company transforming ad experiences for brands and their consumers. Our comprehensive advertising platform seamlessly integrates the capabilities of media, creative, and intelligence to power more than 800 billion impressions and generate more than 300 billion creatives annually, delivering tangible business outcomes for brands and advertisers. Smartly is the only company in the industry recognized as a Leader in The Forrester Wave: Creative Advertising Technologies with PwC validating the results it delivers for brands. We manage creative and media for 700+ brands worldwide and $6B in ad spend across the largest media platforms, including Facebook, Google, Instagram, Pinterest, Snap, and TikTok. Our end-to-end technology, unmatched access to media platforms and exceptional customer service help Fortune 500 brands to reach and engage consumers and learn what performs best.Smartly is a multinational and diverse team of 750+ Smartlies from 60+ nationalities, working in 13 countries. Together, we want to create and maintain an inclusive environment where everyone feels respected and heard. Our Diversity, Equity & Inclusion approach is at the heart of it. Visit Smartly to learn more. The processing of your information is described in our Candidate Privacy Notice.

• Analyze, integrate, and manage data across multiple business systems and applications • Support Business Operations teams by improving system utilization and workflow efficiency • Develop and maintain reports, dashboards, and data models to meet internal, corporate, and project requirements • Interface between cross-functional teams to ensure seamless data flow and system integration • Design and implement automation solutions using scripting and database tools • Maintain and enhance existing tools, including VBA-based applications and SQL queries • Support version control and deployment processes using SVN • Identify opportunities for process improvements and recommend scalable data solutions