Bring us your experience, your head for strategy, your strength with relationships and your eye for opportunity. In return we offer an unmatched place to grow and develop your career among a richly diverse group of businesses driven by the power and stability of a leading health care organization. Come help us heal and strengthen the health care system as you do your life's best work.(sm) The Senior Investigator will be responsible for triaging, investigating and resolving instances of healthcare fraud and / or abusive conduct by the medical profession, insured members or the broker community. This individual will be utilizing information from claims data analysis, plan members, employee's conduct confidential investigations and document relevant findings. They will report any illegal activities in accordance with all laws and regulations. The Senior Investigator may also conduct onsite provider claim and / or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. They will act as a subject matter with identifying, communicating and recovering losses as deemed appropriate. Where applicable. they will provide testimonials regarding the investigation. Primary Responsibilities:Manages database tools for internal processing of various components of pharmacy audit reports received from contracted vendor Maintain daily interface with audit vendor and coordination of network audit functions between ORx and audit vendor Coordinate the development of pharmacy audit result reports as needed Contributes to team effort by consistently meeting established productivity, schedule adherence, and quality standards while maintaining a good attendance record Perform comprehensive Quality Assurance Work collaboratively with others Evaluate metrics and recommend process improvements Demonstrates a clear understanding of goals, objectives, policies, procedures and priorities Oversee / present pharmacy referrals to the Network Provider Evaluation Committee (NPEC) and pharmacy fraud investigation team Initial point of contact for pharmacies in relation to appeals and audit escalation Develops various standard and ad hoc reports Analyzes and investigates Provides explanations and interpretations within area of expertise
Required Qualifications:High School Diploma / GED 2+ years of pharmacy technical experience; i.e. someone who possesses retail and / or PBM knowledge 2+ years of claims auditing experience; i.e. reviewing claims for payment accuracy and correcting incorrect claims; working through the process of correcting claims Excellent verbal and written communication skills; i.e. communicating with pharmacies and lawyers regarding pharmacy audits discussing various audit findings Intermediate to advanced level of proficiency with MS Excel and Access; i.e. performing ad hoc reporting and analysisPreferred Qualifications:College degree Familiarity with pharmacy law within multiple states Familiarity with OptumRx systems Project management experienceCareers 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) 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: Investigator, PBM, Irvine, CA, California
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.