Note: The job is a remote job and is open to candidates in USA. UnitedHealthcare provides consumer-oriented health benefit plans through UMR, its third-party administrator solution. The Senior SIU Analyst identifies emerging fraud schemes, analyzes claims and provider activity, develops investigative intelligence, and supports proactive fraud prevention and loss mitigation. The role also collaborates with investigators and business partners to communicate findings and strengthen fraud detection tools and processes.
Responsibilities
- Monitor claim activity, provider billing patterns, and other data sources to identify anomalies, emerging trends, and potential fraud risks
- Analyze escalations from internal business partners to determine whether issues are isolated events or indicators of broader fraud schemes
- Identify emerging trends and patterns that may signal organized, systemic, or high-risk fraud activity
- Conduct root-cause analyses to understand how fraudulent activity occurs and identify gaps in existing controls and mitigation strategies
- Develop actionable intelligence to support investigations, provider flagging, claim-edit enhancements, payment prevention efforts, and other fraud mitigation initiatives
- Collaborate with SIU investigators and cross-functional stakeholders to translate analytical findings into effective fraud prevention and detection actions
- Quantify avoidance losses resulting from proactive fraud detection, prevention, and intervention efforts
- Leverage data analytics, investigative methodologies, and industry intelligence to prioritize high-risk activities and focus SIU resources where they can have the greatest impact
- Prepare and communicate findings, trends, and recommendations to leadership and business partners to support informed decision-making and fraud prevention strategies
- Support the development and enhancement of fraud detection tools, reporting, and monitoring processes to strengthen proactive fraud identification capabilities
Skills
- High School Diploma / GED OR equivalent work experience
- Must be 18 years of age OR older
- 2+ years of experience analyzing and solving customer problems in an office setting
- Intermediate level of Microsoft Office including Ms Word, PowerPoint, Outlook, Teams (data entry, sorting/filtering, pivot tables)
- Ability to work the hours in the job description
- Ability to keep all company sensitive documents secure (if applicable)
- Required to have a dedicated work area established that is separated from other living areas and provides information privacy
- Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
- All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
- 2+ years of current or previous claims processing or claims quality review experience within UMR Claims Processing System (UMR CPS)/ Jacada. (UMR is UnitedHealthcare's third-party administrator (TPA) solution). (You must be an employee of UMR specifically to have experience with the UMR claims system)
- Experience as an SIU Analyst
- Experience as a SME or team lead
- Experience with Fraud, Waste and Abuse review
- Knowledge of Medical Claims Billing, ICD - 10, CPT and / or HCPC codes
- Familiarity with resources such as Knowledge Central and / or UMR Policies and Procedure
Benefits
- National Remote. You'll enjoy the flexibility to telecommute from anywhere within the U.S.
- We offer weeks of paid training. The duration dependent on how quickly you acclimate to role.
- A comprehensive benefits package, subject to eligibility requirements
- Incentive and recognition programs, subject to eligibility requirements
- Equity stock purchase, subject to eligibility requirements
- 401k contribution, subject to eligibility requirements
- Opportunities are endless for your career development and advancement within UMR
- Provide development for other roles you may be interested in
Company Overview