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 Principal 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 pharmacy community. This individual will be utilizing information from claims data analysis, plan members, tips/referrals to conduct confidential investigations and document relevant findings. They will report any illegal activities in accordance with all laws and regulations. The 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 expert with identifying, communicating and recovering losses as deemed appropriate. Where applicable, they will provide testimonials regarding the investigation. If you are located in Iowa, you will have the flexibility to telecommute* as you take on some tough challenges.Primary Responsibilities: Triage, investigate and resolve instances of pharmacy healthcare fraud and / or abusive conduct by the medical profession, pharmacy profession, and / or insured membersObtain and analyze claims billing and payment data as necessary in the course of conducting complex investigations of allegations of criminal or civil Medicaid fraud Use information from tips and complaints from plan members, the medical community and law enforcement to conduct confidential investigations, document relevant findings and report any illegal activities in accordance with all laws and regulations Conduct onsite provider claim and / or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation (when appropriate)Identify, communicate and recover losses as deemed appropriate Complete root cause analysis Identify gaps and inefficiencies in existing policies and procedures and suggest effective and efficient solutions Act as primary liaison with Pharmacy Benefit Managers, MEDICs, ZPICs, PSCs, law enforcement, prosecutors, Administrative Law Judges, and other regulatory agencies in the area of fraud, waste and abuse detection, investigation and reporting 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: Undergraduate degree or equivalent work experience 3 + years of experience working in a Compliance organization, fraud investigation unit, or law enforcement agency 3+ years of experience / employment with a PBM and / or a pharmacy An intermediate level of proficiency in MS Excel and MS Word Must live within a commutable distance of the location listed for this specific career opportunityPreferred Qualifications: Industry Certification (CFE, AHFI) Healthcare fraud experience Excellent verbal and written communication skillsExperience with Medical/Pharmacy, Fraud Waste and Abuse (FWA)Experience with a Pharmacy Benefit Manager (PBM) Pharmacy claims processing knowledge and Certified Pharmacy Technician (CPhT) Previous experience with government healthcare programs (Medicare, Medicaid and / or TriCare) An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to insurance *All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy 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: Principal Investigator, Investigation, Fraud, Compliance, Investigations, Accredited Healthcare Fraud Investigator (AHFI) , Certified Fraud Examiner (CFE) , Certified Professional Coder (CPC), Medical/Pharmacy, Fraud Waste and Abuse (FWA), Pharmacy Benefit Manager (PBM), Local, State & Federal laws and regulations, law enforcement investigation, insurance claims, Investigate, Prevent and Enforce Violations, Health Care Fraud Investigator, specializing in Medical/Provider Fraud, Iowa, IA
Internal Number: 756768
About UnitedHealth Group
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.