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Investigations Consultant- New York, NY (Primary) or Iselin, NJ (Office- Based)

UnitedHealth Group • New York, NY

Posted 9 days ago

Job Snapshot

Full-Time
Healthcare - Health Services
Health Care

Job Description

There's no sugar coating it fraud is rampant in health care. And with a projected total spend at nearly $3 trillion, the stakes couldn't be higher. But it's not just the financial losses that we're worried about. We're in the business of making the health care system work better for everyone, so the abuse impacts millions of lives too. As a Lead Investigator, you'll review claims, look for patterns of potential fraud, waste and/or abuse and interact with medical providers to complete investigations. You'll be fully invested in the outcomes and will be helping the health system work better for everyone with the support and resources of a Fortune 6 industry leader.

The Investigative Consultant, working under the general direction and oversight of the Special Investigations Unit (SIU) Manager, will conduct investigations of 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.

Primary Responsibilities
Under the direction of the SIU Manager, the Investigations Consultant 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

  • Lead special projects

  • Prepare reports of SIU activity to assist the SIU Manager in presentation of final reports to the Board of Directors, state and regulatory agencies, the health plans or UHC Senior Management

  • Assist the SIU Manager in execution of the Manager’s responsibilities in the Manager’s absence

Required Qualifications



  • Undergraduate Degree or equivalent work experience

  • 5+ years of experience working in a Compliance organization, fraud investigation unit, pharmacy benefit manager (PBM), law enforcement agency and/or pharmacy

  • 3+ years of experience/employment with a PBM and/or a pharmacy.

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

  • Intermediate proficiency in MS Office (Excel, Word, PowerPoint and Outlook)

  • Must live within the vicinity of Iselin, NJ or New York, NY (primary)

  • Up to 50 % travel within the states listed for this specific career opportunity.

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.)

  • Undergraduate degree in the area of Criminal Justice, Business, or related field

  • Knowledge of Local, State and Federal laws, regulations and administrative codes for pharmacies

Every day, we work to make communities healthier. It's the promise that is at the core of who we are. And our employees' expertise makes all the difference in achieving our goal. Join our elite team today and start doing your life's best work.(sm)

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 key words: New York, NY, New Jersey, New York, NY, PBM, Pharmacy, Medicare, Medicaid, TriCare, Investigations, FWA, Compliance

Job ID: 2551_770738
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