Healthcare Fraud Analyst
Role Overview
We are seeking a Healthcare Monitoring and Risk Analyst to join our team and serve as a critical line of defense in safeguarding patient safety, care integrity, and compliance standards. In this role, you will actively monitor clinical and operational activities, identify irregularities or potential risks, and take prompt action to protect patients, providers, and the organization.
You will be responsible for real-time monitoring of healthcare workflows, investigation of alerts, case review and resolution, and support for patient account or access-related incidents. Your ability to evaluate risk, apply clinical or operational judgment, and escalate concerns appropriately will be essential in minimizing safety and compliance risks.
This position requires the ability to work independently, including off-hours or weekend shifts, while adhering to established clinical protocols, escalation pathways, and regulatory requirements. Success in this role demands strong analytical skills, attention to detail, sound decision-making, and a high level of accountability.
Core Qualifications- 1–2 years of experience in healthcare operations, risk management, compliance, or investigations, preferably in:
o Clinical or operational monitoring
o Patient account or billing review
o Case management or dispute resolution
o Patient access or record integrity investigations- At least 1 year of experience in a monitoring or operations environment, working with real-time dashboards, alerts, or queue-based workflows
- Minimum 2 years of experience working independently, demonstrating sound judgment and decision-making within established healthcare guidelines and compliance standards
- Experience in healthcare systems, patient safety, compliance, or revenue cycle operations
- Comfortable working in a 24/7 or shifting schedule environment
- Familiar with escalation protocols, service level agreements (SLAs), and documentation standards in regulated healthcare environments (e.g., HIPAA compliance)
- Strong analytical skills with the ability to identify unusual patterns, trends, or anomalies in clinical or operational data
- High attention to detail with disciplined, accurate documentation practices
- Sound judgment in assessing risk, including knowing when to act and when to escalate
- Comfortable working with:
o Monitoring dashboards and alert systems
o Case management and issue resolution workflows- Excellent written communication skills, particularly in:
o Case summaries and investigation reports
o Trend analysis and risk reporting
o Updates for leadership or compliance teams
Key Responsibilities- Monitor real-time dashboards to identify potential risks, irregularities, or patient safety concerns
- Investigate alerts and assess the validity of clinical or operational activities
- Conduct thorough reviews of patient cases, billing discrepancies, or access-related issues
- Handle patient account or access integrity cases, ensuring clear documentation for handoff and escalation
- Escalate potential risks or compliance concerns promptly to leadership or appropriate stakeholders
- Prepare regular monitoring summaries, trend analyses, and key risk insights
- Maintain accurate, detailed, and audit-ready documentation for all reviews and investigations
- Market Competitive Pay Levels
- Retirement Plan
- Medical Plan (HMO) from Day 1 of employment
- Dental, Medical, and Optical Reimbursements
- Life and Disability Insurance
- Paid Time-Off Benefits
- Sick Leave Conversion
- Tuition Fee Reimbursement
- Employee Assistance Program (EAP)
- Annual Performance Based Merit Increases
- Employee Recognition
- Training and Staff Development
- Employee Referral Program
- Employee Volunteerism Opportunity
- All Mandatory Statutory Benefits
- Optum is the health care technology and innovation company of the UnitedHealth Group enterprise along with UnitedHealthcare.
- UnitedHealth Group is a health care and well-being company with a mission to help people live healthier lives and help make the health system work better for everyone.
- We’re a leading health solution and care delivery organization. Our work is complex, but our mission is simple: create a healthier world, with you at the center.
- As part of a Fortune 5 enterprise, we are improving the health care experience of over 125 million people around the world.
- Elevate your career with a leading health care company while improving lives.
Join us in evolving health care so everyone can have the opportunity to live their healthiest life. This is your opportunity to be part of a team that’s dedicated to Caring. Connecting. Growing together.