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UnitedHealth Group Pharmacy Audit Investigator - Irvine, CA or US Telecommute in Irvine, California

Energize your career with one of Healthcare’s fastest growing companies.

You dream of a great career with a great company – where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it’s a dream that definitely can come true. Already one of the world’s leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up.

This opportunity is with one of our most exciting business areas: Optum – a growing part of our family of companies that make UnitedHealth Group a Fortune 5 leader.

Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.

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 Pharmacy Audit 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.

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.

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

  • Perform onsite and desktop investigative audits targeting potentialPharmacy FWA

  • Adheres 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 Manager, Sr. Investigator, and Sr. Auditors to supportoverall FWA prevention and detection efforts and ensure case quality

  • Works on special projects as assigned

  • Supports the training and development of Sr. Auditors

  • Provides ideas and recommendations on process improvements

Required Qualifications:

  • High school diploma / GED (orhigher)

  • 2+ years of experienceworking in pharmacy audit, PBM, healthcare investigations, or healthinsurance environment

  • 1+ years pharmacy benefitsmanagement investigations experience

  • 3+ years of experience in aposition processing pharmacy claims and/or investigating fraud

  • In - depth knowledge ofpharmacy operations

  • Current and unrestrictedPharmacy Technician License for the state of residence

  • Must be currently certifiedby the PTCB (Pharmacy Technician Certification Board)

  • Microsoft Office (Word -creating and editing documents, Excel - creating and maintainspreadsheets)

  • Ability to travel up to 25%of the time

  • Monday through Friday 6am to3pm, 7am to 4pm or 8am to 5pm PST

Preferred Qualifications:

  • Bachelor's degree (or higher)

  • Proficient in RxClaim andOnline Reporting

  • An intermediate level ofknowledge with Local, State & Federal laws and regulations pertainingto 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)

OptumRx is an empowering place for people with the flexibility to help create change. Innovation is part of the job description. And passion for improving the lives of our customers is a motivating factor in everything we do.

If you're ready to talk about groundbreaking interactions, let's talk about what happens when a firm that touches millions of lives decides to gather results from millions of prescriptions every month and analyze their impact. Let's talk about smart, motivated teams. Let's talk about more effective and affordable healthcare solutions. This is caring. This is great chemistry. This is the way to make a difference. We're doing all this, and more, through a greater dedication to our shared values of integrity, compassion, relationships, innovation and performance. Join us and start doing your life’sbest work. SM

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

Keywords: Investigator, Pharmacy Tech, Pharmacy Technician, PTCB, PBM, fraud, investigations, Irvine, CA, California