Pharmacy Audit Investigator

Company: UnitedHealth Group
Location: Irvine
Posted on: September 14, 2023

Job Description:

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.--Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and--your life's best work.(sm)You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.Primary Responsibilities:

• Analyzes and monitors industry publications and press releases to be aware of fraud, waste, and abuse (FWA) schemes (HPMS FWA-AICE, NHCAA, HHS-OIG, DOJ, etc.) impacting pharmacy business
• Perform onsite and desktop investigative audits targeting potential Pharmacy FWA
• Adhere to all applicable requirements for case process and quality
• Prepares reports and presentations based on case results
• Conducts onsite audits at pharmacies to assess physical premises, compliance with regulatory requirements, and completeness of records
• Collaborates with the team to support overall FWA prevention and detection efforts and ensure case quality
• Work on special projects as assigned
• Provides ideas and recommendations on process improvementsWhat are the reasons to consider working for UnitedHealth Group?-- Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success.--Some of our offerings include:
  • Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
  • Medical Plan options along with participation in a Health Spending Account or a Health Saving account
  • Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
  • 401(k) Savings Plan, Employee Stock Purchase Plan
  • Education Reimbursement
  • Employee Discounts
  • Employee Assistance Program
  • Employee Referral Bonus Program
  • Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
  • More information can be downloaded at:--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:
    • High School Diploma/GED (or higher)
    • Current and unrestricted Pharmacy Technician License for the state of residence
    • National Pharmacy Technician Certification (Such as PTCB)
    • 2+ years of experience in a government, legal, law enforcement, investigations, healthcare, managed care and/or health insurance environment
    • 2+ years of experience--processing pharmacy or medical claims and/or investigating fraud (health care fraud investigations experience preferred)
    • Intermediate level of knowledge of pharmacy operations
    • Beginner level of proficiency with--Microsoft Office (Word - creating and editing documents, Excel - creating and maintain spreadsheets)
    • Ability to work Monday through Friday 6am to 3pm, 7am to 4pm or 8am to 5pm PST
    • Ability to travel up to 25% of the timePreferred Qualifications:
      • Bachelor's Degree (or higher) in criminal justice or related field
      • Certified Coding Specialist
      • Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI)
      • 2+ years of experience working in the group health business, Including claims processing
      • Intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy and/or commercial health insurance)
      • Proficient in RxClaim or--other pharmacy claims processing systemsSoft Skills:
        • Experience working independently and researching/conducting investigations; must be analytical, self-motivated, goal oriented and have the ability to successfully investigate complex issues*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.--Colorado, Connecticut, Nevada or New York City Residents Only:--The salary range for Colorado residents is $45,100 to $80,200. The salary range for--Connecticut / Nevada / New York City--residents is $49,800 to $88,200. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.--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.--Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.#RPO, #Green

Keywords: UnitedHealth Group, Irvine , Pharmacy Audit Investigator, Healthcare , Irvine, California