Investigative Consultant - Dallas or Houston, TX

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 Investigative Consultant, working under the general direction and oversight of the Special Investigations Unit (SIU) Manager, will conduct desktop and onsite reviews of UnitedHealth Group's Pharmacy Network and execute UnitedHealthcare's a Fraud, Waste, and Abuse (FWA) Credentialing process for independent pharmacies located within high-risk counties, seeking entrance into the Pharmacy Network. They will conduct complex investigations involving suspected civil or criminal fraud in connection with Medicare or Medicaid, or Commercial business.

In addition to OptumRx's Credentialing of Contracted Pharmacies processes, UnitedHealthcare SIU shall execute and administer an enhanced fraud, waste and abuse credentialing program of independent-retail pharmacies seeking entry into the OptumRx Pharmacy Network, located within high-risk counties as identified by Center for Medicare & Medicaid Services (CMS). This position will serve as a regional investigator for the Independent Pharmacy Enhanced Credentialing (IPEC) program - jurisdiction will cover Texas.

Primary Responsibilities:

• Identify gaps and inefficiencies in existing policies and procedures and suggest effective and efficient solutions


• Investigative Consultant will verify the validity of all address(es) associated to a High-Risk Pharmacy including, but not limited to, Google Map's searches and/or on-site visits


• Investigative Consultant will perform background checks on all 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


• Investigative Consultant will validate one (1) years' worth of purchase invoices and/or other applicable documentation, as well as correlating billing records


• Investigative Consultant will verify current on-hand inventory, as well as acquire a complete listing of wholesaler(s)


• Investigative Consultant will execute unannounced pharmacy inspections, to ensure compliance with state and/or federal regulations, codes and statutes


• Obtain and analyze claims billing and payment data as necessary in the course of conducting complex investigations of allegations of criminal or civil fraud


• Testify in criminal, civil and/or administrative proceedings as required


• Interview witnesses who have knowledge of alleged fraud/abuse activity


• Prepare comprehensive case investigation reports including evidence and findings

Required Qualifications:

• Bachelor's Degree in Business or Criminal Justice or related field (Significant investigations work experience in lieu of Bachelor's Degree will be considered)


• 5+ years of experience working in a Compliance organization, fraud investigation unit, pharmacy benefits manager, law enforcement agency or pharmacy


• Previous experience with government healthcare programs (Medicare, Medicaid and/or TriCare)


• Previous experience/employment with a Pharmacy Benefit Manager (PBM) or a pharmacy

Preferred Qualifications:

• Certified Pharmacy Technician (CPhT)


• Industry Certifications, i.e. CFE, AHFI, etc.


• Pharmacy claims processing knowledge


• Knowledgeable on Federal/State Requirements and Administrative Rules for Pharmacies


• Proficient in MS Excel

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 14 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: 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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