Healthcare Claims Investigator

About the role

Optum is seeking a Healthcare Claims Investigator to join its San Juan team. You will play a critical role in protecting the integrity of health plans by investigating potential fraud, waste, and abuse, and ensuring compliance with state and federal regulations.

Key responsibilities

• Triaging, investigating, and resolving instances of healthcare fraud or abusive conduct.
• Conducting confidential investigations using tips, complaints, and data from members, providers, and law‑enforcement.
• Performing onsite provider claim or clinical audits to gather necessary documentation.
• Communicating findings to clients, regulators, and stakeholders and, when required, providing testimony.
• Collaborating with clinical coding consultants and external sources to identify emerging fraud patterns.
• Monitoring investigation status, documenting progress, and completing root‑cause analyses.
• Supporting special projects, reporting, and data‑mining activities.

Required profile

• Minimum 2 years of experience in claims investigation or related healthcare fraud analysis.
• Strong analytical mindset with the ability to interpret medical records and claims data.
• Excellent written and verbal communication skills in English.
• Ability to work independently on complex, less‑structured issues.
• Willingness to undergo an English proficiency assessment after application.

Required skills

What we offer

• Inclusive culture focused on career development and comprehensive benefits.
• Opportunities to make a direct impact on health outcomes for millions of people.
• Potential for growth within a global organization.