Pharmacy Investigator - Remote in MI

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 Pharmacy Investigator reports directly to the Manager of Investigations, and is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse. The Pharmacy Investigator will utilize claims data, applicable guidelines and other sources of information to identify aberrant billing practices and patterns. The Pharmacy Investigator is responsible for conducting investigations which may include field work to perform interviews and obtain records and/or other relevant documentation.

If you reside in Michigan, you will enjoy the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities
• 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
• 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
• Travel 50% or more in the greater Southfield, MI area

What Are The Reasons To Consider Working For UnitedHealth Group? Put It All Together - Competitive Base Pay, a Full And Comprehensive Benefit Program, Performance Rewards, And a Management Team Who Demonstrates Their Commitment To Your Success. Some Of Our Offerings Include
• 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.)
• More information can be downloaded at: http://uhg.hr/uhgbenefits

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.

Required Qualifications
• Associate’s Degree (or higher) and 2+ years of healthcare related experience
• 2+ years of experience in health care fraud, waste, and abuse (FWA)
• 2+ years of experience in state or federal regulatory FWA requirements
• 2+ years of experience with analyzing data to identify fraud, waste and abuse trends
• Intermediate level of proficiency in Microsoft Excel and Word
• Ability to travel up to 50% to provider facilities as needed
• Ability to participate in legal proceedings, arbitration, and depositions at the direction of management

Preferred Qualifications
• National Health Care Anti-Fraud Association (NHCAA)
• Demonstrated intermediate level of knowledge in health care policies, procedures, and documentation standards or 2-5 years of experience
• Demonstrated intermediate level of skills in developing investigative strategies or 2-5 years of experience
• Specialized knowledge/training in healthcare FWA investigations
• Active affiliations:
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• License and/or Certified Pharmacy Technician (CPhT)
• Intermediate knowledge in pharmacy claims processing
• Operational experience with a pharmacy and/or pharmacy benefits manager (PBM)
• All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

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.

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