Investigator - Audit - Philadelphia, PA, Irvine, CA, or NJ Telecommute

UHG Irvine, PA

About the Job

Here's a statistic that will stop you cold: Our country spends nearly $3 trillion on health care annually. With that kind of money at play, you can be sure some individuals will figure out a way to get a piece of it illegally. Now, that doesn't even take into account the millions of lives that are held in the balance as well. This is fraud on a scale you couldn't begin to imagine. As a Senior Investigator, you will play a part in putting a stop to it. It's critical work that that you will want to be a part of. Apply today.


If you are located in Philadelphia, PA, Irvine, CA, or NJ  you will have the flexibility to telecommute* as you take on some tough challenges.


Primary Responsibilities:

  • Analyzes and monitors industry publications to be aware of fraud, waste, and abuse (FWA) schemes (PLATO, CMS / MEDIC, OIG, Google Alerts, etc.) impacting pharmacy business
  • Researches and monitors assigned region for potential Pharmacy FWA
  • Prepares reports and presentations based on identified schemes
  • Builds and maintains relationship with government enforcement agencies
  • Collaborates with clients
  • Leads planning and creates proposals  for onsite audit projects
  • Conducts onsite audits at pharmacies to assess physical premises, compliance with regulatory requirements, and completeness of provider / clinical records and itemized bills
  • Presents schemes or case outcomes during committee (NPEC) and other departmental meetings as appropriate
  • Reviews and assesses quality and accuracy of audit conducted by analysts and / or sr. auditors
  • Collaborates with Manager, Supervisor, Analysts and Sr. Auditors to support overall FWA prevention and detection efforts and ensure case quality
  • Leads special projects as assigned
  • Trains and develops analysts, and assists in training new hires
  • Provides ideas and recommendations on process improvements

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.

Required Qualifications:

  • High school diploma
  • 3+ years of experience working in pharmacy audit, PBM, healthcare investigations, or health insurance environment
  • 1+ year 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
  • Currently certified by the PTCB (Pharmacy Technician Certification Board)
  • Strong skills with Microsoft Office (Word, Excel, Access)
  • Excellent communication skills, written and verbal
  • Strong organizational skills; must be detail - oriented
  • Ability to travel up to 25% of the time

Preferred Qualifications:

  • Bachelor's degree
  • 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)



Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)


*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy


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.



Job Keywords: Senior Investigator, Pharmacy Tech, Pharmacy Technician, PTCB, PBM, fraud, investigations, Irvine, CA, California, Philadelphia, PA, Pennsylvania, New Jersey