Job details
Job type full-time
Full job description
Here`s a statistic that will stop you cold: our country spends nearly $3 trillion on health care annuallyWith that kind of money at play, you can be sure some individuals will figure out a way to get a piece of it illegallyNow, that doesn`t even take into account the millions of lives that are held in the balance as wellThis is fraud on a scale you couldn`t begin to imagineAs a pharmacy audit investigator, you will play a part in putting a stop to itIt`s critical work that that you will want to be a part ofApply today.
The challenge for you will be the high volume of cases on your plate at one timeYou will be part of a team responsible for triaging, investigating and resolving instances of healthcare fraud and / or abusive conduct.
You’ll enjoy the flexibility to telecommute* from anywhere within the u.sAs you take on some tough challenges.
Primary responsibilities:
Analyzes and monitors industry publications and press releases to be aware of fraud, waste, and abuse (fwa) schemes (hpms fwa-aice, nhcaa, hhs-oig, doj, etc.) impacting pharmacy business
Perform onsite and desktop investigative audits targeting potential pharmacy fwa
Adhere to all applicable requirements for case process and quality
Prepares reports and presentations based on case results
Conducts onsite audits at pharmacies to assess physical premises, compliance with regulatory requirements, and completeness of records
Collaborates with the team to support overall fwa prevention and detection efforts and ensure case quality
Work on special projects as assigned
Provides ideas and recommendations on process improvements
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 :
High school diploma or ged
2+ years of experience working in a government, legal, law enforcement, investigations, healthcare, managed care and/or health insurance environment
2+ years of experience in a position processing pharmacy or medical claims and/or investigating fraud (health care fraud investigations experience preferred)
Experience working independently and researching/conducting investigations; must be analytical, self-motivated, goal oriented and have the ability to successfully investigate complex issues
In - depth knowledge of pharmacy operations
Current and unrestricted pharmacy technician license for the state of residence
Must be currently certified by the ptcb (pharmacy technician certification board)
Microsoft office (word - creating and editing documents, excel - creating and maintain spreadsheets)
Ability to travel up to 25% of the time
Monday through friday 6am to 3pm, 7am to 4pm or 8am to 5pm pst
Preferred qualifications:
Bachelor`s degree or higher in the area of criminal justice or related field
2+ years of experience working in the group health business preferred, particularly within claims processing
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)
Proficient in rxclaim or other pharmacy claims processing systems
Certified coding specialist
Certified fraud examiner (cfe) or accredited healthcare fraud investigator (ahfi)
Careers with unitedhealthcareLet`s talk about opportunityStart with a fortune 5 organization that`s serving more than 85 million people already and building the industry`s singular reputation for bold ideas and impeccable executionNow, add your energy, your passion for excellence, your near-obsession with driving change for the betterGet the picture? unitedhealthcare is serving employers and individuals, states and communities, military families and veterans where ever they`re found across the globeWe bring them the resources of an industry leader and a commitment to improve their lives that’s second to noneThis is no small opportunityIt`s where you can do your life`s best work.(sm)
Unitedhealth group requires all new hires and employees to report their covid-19 vaccination status.
*all telecommuters will be required to adhere to unitedhealth group’s telecommuter policy.
Colorado residents only: the hourly range for colorado residents is $43,200 to $76,700Pay is based on several factors including but not limited to education, work experience, certifications, etcAs of the date of this posting, in addition to your salary, unitedhealth group offers the following benefits for this position, subject to applicable eligibility requirements: health, dental and vision plans; wellness program; flexible spending accounts; paid parking or public transportation costs; 401(k) retirement plan; employee stock purchase plan; life insurance, short-term and long-term disability insurance; business travel accident insurance; employee assistance program; paid time off; and employee-paid critical illness and accident insurance.
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 workplaceCandidates are required to pass a drug test before beginning employment
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