Pharmacy Investigator - Remote in NY, NJ, PA
About the position 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 to start Caring. Connecting. Growing together. The Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. The Investigator will utilize claims data, applicable guidelines and other sources of information to identify aberrant billing practices and patterns. The Investigator is responsible to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.
Responsibilities
- Assess complaints of alleged misconduct received within the Company
- Investigate low to medium 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
- 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
- Communicate effectively, including written and verbal forms of communication
- Develop goals and objectives, track progress and adapt to changing priorities
Requirements
- Bachelor's Degree OR Associate's Degree
- 2+ years of equivalent work experience with healthcare related employment
- Basic level of proficiency in Microsoft Excel and Word
- Ability to travel up to 50% within PA, NY, and NJ
- Reside in PA, NY, or NJ - commutable distance to Philadelphia, Kings, and Essex counties
- Ability to participate in legal proceedings, arbitration and depositions at the direction of management
- Access to reliable transportation and valid US driver's license
Nice-to-haves
- License and/or Certified Pharmacy Technician (CPhT)
- Accredited Health Care Fraud Investigator (AHFI)
- Basic level of knowledge in health care policies, procedures and documentation standards
- Basic level of skills in developing investigative strategies
- Basic level of knowledge in pharmacy claims processing
- Specialized knowledge/training in healthcare fraud, waste and abuse (FWA) investigations
- Basic level of knowledge in analyzing data to identify FWA trends
- Basic level of knowledge in state and federal regulatory FWA requirements
- Active affiliations: National Health Care Anti-Fraud Association (NHCAA)
- Certified Fraud Examiner (CFE)
- 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.)
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