Title: Coding Investigator Auditor (Work From Home) Location: United States Job Description: time type Full time job requisition id R0050654 At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job Summary Summary: This position is responsible for performing Reimbursement Policy (RP) review, creation and publication. Conducting research; preparing documentation of findings as needed. Coordination with all departments involved in each project required such as Special Investigations, Customer Service, Pass, Network Management, Marketing, Case Management, Medical Review, Legal, Pricing And Database. Perform annual review of policies which includes research and providing updates to coding and suggested language changes. Support completion of annual reviews and approvals including recording votes, feedback. Required Job Qualifications: - Bachelor Degree; one year of business experience, law enforcement experience, or regulatory agency experience may substitute for each year of college. - Certified Coding Certification, or acquire within 24 months of hire - 3 years' experience in claims processing operations and reporting systems, including 2 years' experience in auditing or developing computer system reports. - Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation. - Awareness of claims processes and claims processing systems. - PC proficiency to include Microsoft Word and Excel and health insurance databases. - Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings. - Organizational skills and prioritization skills Preferred Job Qualifications: - Certified Coding Certification - HIGHLY PREFERRED - Support CWG (Coding Work Group) and other policy related meetings. - Clear and consistent post-meeting summarization and professional communication/presentation skills. - Familiar with AP Style (Associated Press): Standard for journalism and public relations, focusing on brevity, consistent spelling, and abbreviations - Experience leading annual audit of policy utilization and charter update, to include policy improvement, voting roster, etc. - Support and create policy summaries - Perform routine auditing - Audit/review Plan RP sites to ensure the accuracy/timing of the posted policies - Work with Corp Comms on ideas/ solutions for process improvement Sponsorship will not be provided for this role. This position is Telecommute (Work From Home). #LI-LI1 #LI-Remote Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process! Pay Transparency Statement: At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan. HCSC Employment Statement: We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics Base Pay Range $55,900.00 - $123,500.00 Exact compensation may vary based on skills, experience, and location.

Role Description The Senior Auditor - Field Compliance & Investigations supports field compliance, investigation oversight, and audit quality across assigned NI-ABAE states. The role combines field audits, investigation review, evidence validation, report review, and auditor supervision. This is a field-facing role requiring up to 3 field days per week, focused on high-risk clinics, priority operational issues, investigations, and gaps identified through audit trends or report reviews. The successful candidate must be able to assess whether field findings are supported by evidence, identify missed risks, and provide clear, actionable feedback to improve audit quality and program accountability. What Success Looks Like in This Role: - Plan field audits based on risk, not routine clinic rotation. - Identify high-risk clinics, unresolved issues, and operational gaps requiring follow-up. - Review reports critically and identify unsupported conclusions or weak evidence. - Conduct field validation and investigations professionally and objectively. - Escalate serious concerns with clear evidence and recommended next steps. - Improve the quality of auditor submissions through coaching and feedback. - Maintain strong follow-up and support issue resolution through closure. - Balance field presence, investigation quality, and timely reporting. Key Responsibilities - Risk-Based Field Audits & Compliance: - Conduct field audits and investigations across assigned states. - Prioritize high-risk clinics based on audit trends, unresolved issues, dashboard indicators, staff performance gaps, and operational risks. - Review clinic operations, conditional cash transfer compliance, and adherence to NI-ABAE protocols. - Validate findings using field observations, caregiver interviews, staff interviews, dashboards, records, and supporting documentation. - Identify operational risks affecting compliance, retention, coverage, fraud prevention, and program quality. - Investigation Review & Fraud Risk: - Support confidential investigations involving staff conduct, clinic operations, caregiver payments, and suspected fraud. - Conduct field validation where necessary to assess allegations and gather supporting evidence. - Review investigation reports for missing evidence, unsupported conclusions, inconsistencies, and weak validation. - Distinguish between fraud, protocol violations, performance gaps, training gaps, and operational control weaknesses. - Escalate serious concerns with clear evidence and recommended action. - Report Review & Evidence Quality: - Review Staff Work Day, audit & investigation reports, and related field outputs. - Identify weak validation, missed risks, unclear recommendations, and unsupported conclusions. - Provide clear and actionable feedback to auditors to improve field validation, evidence quality, and reporting standards. - Ensure reports clearly explain the findings, the evidence reviewed, the actions taken, and the required follow-up. - Team Supervision & Coaching: - Provide technical supervision and guidance to auditors across assigned states. - Review auditor work plans to ensure field activities are prioritized based on risk. - Coach auditors on investigation quality, field validation, escalation standards, and report writing. - Identify repeated performance gaps and support auditor development through follow-up and coaching. - Risk Monitoring & Continuous Improvement: - Use dashboards, audit trends, field reports, and investigation findings to identify high-risk clinics, staff, or operational processes. - Support improvements to audit tools, protocols, and training materials. - Contribute to fraud prevention, compliance monitoring, and audit quality improvement initiatives. - Support ongoing training for auditors, managers, and field teams on compliance and investigation standards. Qualifications - 3-5 years of experience in field audit, compliance, internal control, fraud investigation, program assurance, field verification, monitoring and evaluation, or related roles. - Experience conducting field audits, investigations, or operational reviews. - Experience reviewing field reports, validating evidence, and assessing operational compliance. - Experience using data or audit trends to prioritize high-risk field visits. - Experience working in NGO, donor-funded, health, public sector, humanitarian, or field operations environments is strongly preferred. - Prior experience supervising or coaching auditors or field teams is an advantage. Education & Certifications - Bachelor's degree in Accounting, Finance, Social Sciences, Public Health, Development Studies, Criminology, Statistics, or a related field. - Professional certification, such as ICAN, ACCA, ACA, CIA, CFE, or relevant compliance/investigation training, is an added advantage. Required Skills & Competencies - Technical Skills: - Strong field audit and investigation judgment. - Risk-based audit planning and operational review. - Evidence validation and report review. - Fraud risk and compliance assessment. - Strong written reporting and documentation skills. - Ability to review dashboards, records, and operational data. - Proficiency in Microsoft Office, Google Sheets, Google Docs, and smartphones. - Behavioral Competencies: - Strong accountability and follow-up. - Clear communication and feedback skills. - Ability to handle confidential matters professionally. - Independent thinking and sound judgment. - Ability to work under pressure and adapt in field environments. - Strong organizational and time management skills. Language Requirement - Proficiency in the English Language (conversation, reading, and writing) is required. - Knowledge of the Hausa Language (conversation and reading) is preferred. - Ability to speak local languages in NI-ABAE operating states is an added advantage. This Role May Not Be a Good Fit If… - You are looking for a mainly desk-based audit role. - You are not comfortable spending up to 3 days per week in the field. - You prefer routine checklist audits over risk-based field reviews. - You are uncomfortable visiting high-risk clinics or following up on sensitive issues. - You prefer to rely only on what staff or stakeholders say without independently validating information. - You are uncomfortable reviewing other auditors' reports and giving clear feedback. - You avoid escalating serious concerns because they are sensitive or difficult. - You struggle to write clear, evidence-based reports. - You are uncomfortable handling confidential investigations or sensitive staff issues. Application Process - Shortlisted candidates will complete a practical assessment focused on audit judgment, evidence review, investigation thinking, and report quality. - Candidates are encouraged to apply early as applications will be reviewed on a rolling basis. DISCLAIMER: Beware of fraudulent job offers. New Incentives – All Babies Are Equal Initiative does not charge a fee at any stage of the recruitment process. Women and persons with disabilities are strongly encouraged to apply for this position! All internal application and employee are strongly advised to use their official email address while applying. All submissions should be sent by filling out this Google Form . Applications will be reviewed on a rolling basis.

• Review ICD-10 codes to ensure correct clinical category mapping • Identify missed reimbursement opportunities across PT/OT, SLP, NTA, Nursing, and Functional Scoring • Ensure therapy services and clinical documentation are properly aligned • Utilize CMS tools, the RAI Manual, and internal protocols to maintain regulatory compliance • Thoroughly scrub assessments prior to submission for completeness and accuracy

Title: Secondary Review Nurse - Indiana Location: Indianapolis, Indiana Work Type: Remote, Full Time Job ID: 2363768 Job Description: At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The Secondary Review Nurse plays a critical role in evaluating clinical requests for Home and Community-Based Services (HCBS). This position ensures that care provided is medically necessary, cost-effective, and tailored to the individual needs of each member, while remaining compliant with state regulations. If you reside within the state of Indiana, you will enjoy the flexibility to work remotely * as you take on some tough challenges. Primary Responsibilities: - Participate in secondary reviews for HCBS services and Medicaid services - Review and process prior authorization requests for LTSS and HCBS services - Apply clinical judgment and decision support tools to determine medical necessity and appropriateness of services - Collaborate with care managers, physicians, and other stakeholders to ensure continuity of care and alignment with the members' service plan - Monitor utilization patterns and identify opportunities for improved care coordination and cost containment - Document all clinical decisions and communications in accordance with regulatory and organizational standards - Support quality improvement initiatives and participate in developing education and training for staff - Identify potential quality of care concerns, including instances of over/or underutilization of services and escalate these issues as needed - Stay current with established guidelines and regulatory requirements You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: - Current, unrestricted RN license in the state of Indiana - 3+ years of clinical experience in a hospital, acute care, home health / hospice, direct care or case management, able to quickly identify needs and issues - 2+ years of experience with completing functional assessments for LTSS services - 2+ years of experience with Medicaid, Medicare, or Managed Care and Long Term Services and Supports - Intermediate level of knowledge of LTSS experience determining eligibility and appropriate allocation of services - Intermediate level of computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications Preferred Qualifications: - Pre-authorization experience - Utilization Management experience - Case Management experience - Knowledge of state and federal guidelines - Home health or hospice - Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action - 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 hourly pay for this role will range from $28.94 to $51.83 per hour based on full-time employment. We comply with all minimum wage laws as applicable. 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.