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Pharmacy Investigator

Company: UnitedHealth Group
Location: Elmwood Park
Posted on: September 19, 2023

Job Description:

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities, and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable, and equitable. Ready to make a difference? Join us and start doing your life's best work.SM
The--Pharmacy--Investigator--reports directly to the Manager of Investigations. The--Pharmacy--Investigator--is responsible for identification, investigation and prevention of healthcare fraud, waste, and abuse. The--Pharmacy--Investigator--will utilize claims data, applicable guidelines, and other sources of information to identify aberrant billing practices and patterns. The--Pharmacy--Investigator--is responsible to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.
If you reside in New Jersey, New York, or Pennsylvania, you'll enjoy the flexibility to telecommute* as you take on some tough challenges.--
Primary Responsibilities:

  • 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 later
  • Communicate effectively, to include 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 work-groups or regulatory meetings
    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:
    • Bachelor's Degree (or higher) OR Associate's Degree with 2+ years of work experience within healthcare field
    • 2+--years of experience in health care fraud, waste, and abuse (FWA)
    • 2+--years of experience in state or federal regulatory FWA requirements
    • 2+--years of experience analyzing data to identify fraud, waste and abuse trends
    • Intermediate level of proficiency with Microsoft Excel and Word
    • Reside in the states of New Jersey, New York, or Pennsylvania with the ability to travel up to 50% in the tri-state area (i.e., NJ, NY, PA)
    • Ability to--participate in legal proceedings, arbitration, and depositions at the direction of management
      Preferred Qualifications:
      • 2+--years of experience in health care policies, procedures, and documentation standards
      • 2+--years of experience 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)
        • Licensed and/or Certified Pharmacy Technician (CPhT)
        • Intermediate knowledge in pharmacy claims processing
        • Operational experience with a pharmacy and/or pharmacy benefits manager (PBM)--
          *All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
          New York Residents Only:--The salary range for New York and New York City, New York residents is--$56,300 to $110,400 per year. 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, #Red

Keywords: UnitedHealth Group, New York , Pharmacy Investigator, Healthcare , Elmwood Park, New York

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