Principal Investigator Pharmacy – Los Angeles County, CA

UnitedHealth Group•Los Angeles, CA

14h•Hybrid

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 Principal Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste, and abuse. The Principal Investigator will utilize claims data, applicable guidelines, and other sources of information to identify aberrant billing practices and patterns. The Principal 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%25. Applicants must be within commutable distance to Los Angeles County. If you reside in Los Angeles, CA, you’ll enjoy the flexibility to telecommute as you take on some tough challenges.

Requirements

Associate’s degree
3+ years of experience in fraud, waste and abuse (FWA) investigations/auditing
3+ years of experience with state/federal laws and regulations pertaining to healthcare FWA
3+ years of experience in analyzing data to identify fraud, waste and abuse trends
Ability to participate in legal proceedings, arbitration, and depositions in the direction of management
Demonstrate advanced level of proficiency in Microsoft Excel and Word
Demonstrate advanced level of knowledge in pharmacy claims processing
Reside within the greater Los Angeles County, CA with ability to travel up to 50%25
Access to reliable transportation and valid US driver’s license

Nice To Haves

Specialized knowledge/training in healthcare FWA investigations
Active affiliations with the 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 benefit manager (PBM)

Responsibilities

Assess complaints of alleged misconduct received within the Company
Investigate 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
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