Principal Investigator Pharmacy - Los Angeles County, CA

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

The PrincipalInvestigator is responsible for identification, investigation and prevention of healthcare fraud, waste, and abuse. The PrincipalInvestigator will utilize claims data, applicable guidelines, and other sources of information to identify aberrant billing practices and patterns. The PrincipalInvestigator is responsible for conducting investigations which may include fieldwork to perform interviews and obtain records and/or other relevant documentation. 

Travel: Up to 50%. Applicants must be within commutable distance to Los Angeles County.

If you reside in Los Angeles, CA, you'll enjoy the flexibility to telecommute* as you take on some tough challenges. 

Primary Responsibilities:

• Assess complaints of alleged misconduct received within the Company
• Investigate highly complex cases of fraud, waste, and abuse
• Detect fraudulent activity by members, providers, employees, and other parties against the Company
• Develop and deploy the most effective and efficient investigative strategy for each investigation
• Maintain accurate, current, and thorough case information in the Special Investigations Unit's (SIU's) case tracking system
• Collect and secure documentation or evidence and prepare summaries of the findings
• Participate in settlement negotiations and/or produce investigative materials in support of the latter
• Collect, collate, analyze, and interpret data relating to fraud, waste, and abuse referrals
• Ensure compliance of applicable federal/state regulations or contractual obligations
• Report suspected fraud, waste, and abuse to appropriate federal or state government regulators
• Comply with goals, policies, procedures, and strategic plans as delegated by SIU leadership
• Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at workgroups or regulatory meetings
• Communicate effectively, including written and verbal forms of communication
• Develop goals and objectives, track progress and adapt to changing priorities

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. 

Required Qualifications: 

• Associate's degree
• 3+ years of experience in fraud, waste and abuse (FWA) investigations/auditing
• 3+ years of experience with state/federal laws and regulations pertaining to healthcare FWA  
• 3+ years of experience in analyzing data to identify fraud, waste and abuse trends
• Ability to participate in legal proceedings, arbitration, and depositions in the direction of management
• Demonstrate advanced level of proficiency in Microsoft Excel and Word
• Demonstrate advanced level of knowledge in pharmacy claims processing
• Reside within the greater Los Angeles County, CA with ability to travel up to 50%
• Access to reliable transportation and valid US driver's license 

Preferred Qualifications:  

• Specialized knowledge/training in healthcare FWA investigations
• Active affiliations with the National Health Care Anti-Fraud Association (NHCAA)
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• License and/or Certified Pharmacy Technician (CPhT)
• Operational experience with a pharmacy and/or pharmacy benefit manager (PBM)

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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