As a Pharmacy Audit Investigator, you will play a part in putting a stop to healthcare fraud. It's critical work that that you will want to be a part of. Apply today.
The challenge for you will be the high volume of cases on your plate at one time. You will be part of a team responsible for triaging, investigating and resolving instances of healthcare fraud and / or abusive conduct.
You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
Analyzes and monitors industry publications to be aware of fraud, waste, and abuse (FWA) schemes (HPMS, CMS / MEDIC, OIG, NHCAA, etc.) impacting pharmacy business
Perform onsite and desktop investigative audits targeting potential Pharmacy FWA
Adhere to all applicable requirements for case process and quality
Prepare reports and presentations based on case results
Conduct onsite audits at pharmacies to assess physical premises, compliance with regulatory requirements, and completeness of records
Work on special projects as assigned
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.
High school diploma / GED or higher
2+ years of experience working in pharmacy audit, PBM, healthcare investigations, or health insurance environment
1+ years pharmacy benefits management investigations experience
3+ years of experience in a position processing pharmacy claims and/or investigating fraud
In – depth knowledge of pharmacy operations
Current and unrestricted Pharmacy Technician License for the state of residence
Must be currently certified by the PTCB (Pharmacy Technician Certification Board)
Microsoft Office (Word – creating and editing documents, Excel – creating and maintain spreadsheets)
Ability to travel up to 25% of the time
Monday through Friday 6am to 3pm, 7am to 4pm or 8am to 5pm PST
If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas, In addition, employees must comply with any state and local masking orders.
Bachelor's degree or higher
Proficient in RxClaim and Online Reporting
An 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)
Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI)
Telecommuting is allowed.
Internal Number: 908256
About OptumRx/UnitedHealth Group
Optum, the fast growing part of UnitedHealth Group, is a leading information and technology-enabled health services business. Our teams are dedicated to modernizing the health care system and improving the lives of people and communities.
Serving virtually every dimension of the health system, we work with a diverse set of clients across 150 countries – from those who diagnose and treat patients to those who pay for care, deliver health services, and those who supply the cures. Optum maintains operations across North America, South America, Europe, Asia Pacific and the Middle East. Our innovative partnerships provide technology and tools that enable unprecedented collaboration and efficiency. As a result, we can tap into valuable health care data to uncover insights and develop strategies for better care at lower costs.