Senior Investigator - Miramar, FL or Miami Dade Telecommute

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, working under the general direction and oversight of the Special Investigations Unit (SIU) Manager, will conduct investigations of medium to high complexity involving suspected civil or criminal fraud or abuse, committed against UnitedHealthcare’s Medicare, Medicaid, and / or Commercial books of business.
 
In addition to OptumRx’s Credentialing of Contracted Pharmacies processes, UnitedHealthcare SIU executes and administers an enhanced fraud, waste and abuse (FWA) credentialing program of independent-retail pharmacies, located within specific geographic counties, seeking entry into the OptumRx Pharmacy Network.  This position will serve as a regional investigator for the Independent Pharmacy Enhanced Credentialing (IPEC) program - jurisdiction will primarily cover Florida.
 
Primary Responsibilities:
 
Under the direction of the SIU Manager, the Senior Investigator will:

Verify the validity of all pharmacy credentialing applications associated with a pharmacy by means of conducting internal and external searches, internet research and unannounced pharmacy inspections
Perform background checks on employees / entities as well as further analytics to identify past / present association(s) with pharmacies terminated from the Pharmacy Network and / or engagement in FWA activity
Validate purchase invoices, and / or other applicable documentation, as well as correlating billing records
Execute unannounced pharmacy inspections to ensure compliance with state and/or federal regulations, codes and statutes
Verify current on-hand inventory and acquire a complete listing of wholesaler(s)
Obtain and analyze claims billing and payment data as necessary
Interview witnesses who have knowledge of alleged fraud / abuse activity
Maintain accurate, current and thorough case information in the SIU case tracking database
Gather and document objective evidence and recommend credentialing / contracting of pharmacies based on the investigative findings
Secure documentation and prepare summaries of the findings
Control and maintain Company and departmental data to ensure confidentiality in accordance with Company policy
Report suspected FWA to appropriate federal or state government regulators
Testify in criminal, civil and / or administrative proceedings as required
Attend continuing anti-fraud training
 

Required Qualifications:

2+ years of experience working in a Compliance organization, fraud investigation unit, pharmacy benefit manager (PBM), law enforcement agency and / or pharmacy
1+ experience / employment with a PBM and / or a pharmacy
Previous experience with government healthcare programs (Medicare, Medicaid and / or TriCare)
Intermediate level of proficiency in MS Excel and MS Word
Preferred Qualifications:

Undergraduate degree in the area of Criminal Justice, Business, or related field
Pharmacy claims processing knowledge
Certified Pharmacy Technician (CPhT)
Industry certifications (AHFI, CFE, etc.)
Knowledge of Local, State and Federal laws, regulations and administrative codes for pharmacies
Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can 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: Senior Investigator, Compliance, Fraud, PGM, Pharmacy, CPhT, AHFI, CFE, Miramar, Miami Dade, FL, Florida, telecommute, telecommuter, telecommuting, remote, work from home