[Hiring] Senior Investigator Pharmacy @UnitedHealth Group

Role Description

The Senior Investigator Pharmacy is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. The Senior Investigator will utilize claims data, applicable guidelines and other sources of information to identify aberrant billing practices and patterns. The Senior Investigator is responsible for conducting investigations which may include fieldwork to perform interviews and obtain records and/or other relevant documentation.

Travel: Up to 50%. Applicants must be within commutable distance to Los Angeles County. If you reside in the greater Los Angeles, CA area, you’ll enjoy the flexibility to telecommute as you take on some tough challenges.

Primary Responsibilities:

• Assess complaints of alleged misconduct received within the Company
• Investigate medium to highly complex cases of fraud, waste and abuse
• Detect fraudulent activity by members, providers, employees and other parties against the Company
• Develop and deploy the most effective and efficient investigative strategy for each investigation
• Maintain accurate, current and thorough case information in the Special Investigations Unit’s (SIU’s) case tracking system
• Collect and secure documentation or evidence and prepare summaries of the findings
• Participate in settlement negotiations and/or produce investigative materials in support of the latter
• Communicate effectively, including written and verbal forms of communication
• Develop goals and objectives, track progress and adapt to changing priorities
• Collect, collate, analyze and interpret data relating to fraud, waste and abuse referrals
• Ensure compliance of applicable federal/state regulations or contractual obligations
• Report suspected fraud, waste and abuse to appropriate federal or state government regulators
• Comply with goals, policies, procedures and strategic plans as delegated by SIU leadership
• Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at workgroups or regulatory meetings

Qualifications

• Bachelor’s Degree OR Associate’s Degree with 2+ years of equivalent work experience with healthcare related employment
• 2+ years of experience in healthcare, fraud, waste and abuse (FWA)
• 2+ years of experience in state or federal regulatory FWA requirements
• 2+ years of experience in analyzing data to identify fraud, waste and abuse trends
• Intermediate level of proficiency with Microsoft Excel and Word
• Intermediate level of knowledge in pharmacy claims processing
• Ability to participate in legal proceedings, arbitration, and depositions at the direction of management
• Reside within the greater Los Angeles County, CA area with the ability to travel up to 50%
• Access to reliable transportation and valid driver’s license

Preferred Qualifications

• 2+ years of experience in health care policies, procedures, and documentation standards
• 2+ years of experience in developing investigative strategies
• Specialized knowledge/training in healthcare FWA investigations
• Active affiliations: National Health Care Anti-Fraud Association (NHCAA)
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• License and/or Certified Pharmacy Technician (CPhT)
• Operational experience with a pharmacy and/or pharmacy benefits manager (PBM)

Benefits

• 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.)