Senior Investigator Pharmacy - New Jersey, New York

UnitedHealth Group • New York, NY

16h • Remote

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 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 to conduct investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.
Travel: Up to 50%25. Applicants must be within commutable distance to Philadelphia, Kings, and Essex Counties.
If you reside within New Jersey, New York, you will enjoy the flexibility to telecommute as you take on some tough challenges.

Requirements

• Bachelors degree OR associate degree plus two 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 experience in Microsoft Excel and Word
• Intermediate level of knowledge in pharmacy claims processing
• Must have a valid driver’s license
• Reside in NY or NJ and be willing and able to travel up to 50%25 within PA, NY, and NJ (Philadelphia, Kings, Essex Counties, and surrounding areas)
• Must participate in legal proceedings, arbitration, and depositions at the direction of management

Nice To Haves

• 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
• 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)
• All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

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 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

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.)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level