- Responsible for planning and conducting onsite audit projects
- Document and research all allegations of potential fraud from internal and external sources
- Triage cases to auditors and investigators
- Ensure timely completion of triaged work based on client guidelines
- Analyzes and monitors industry publications to be aware of fraud, waste, and abuse (FWA) schemes (AICE-FWA, CMS / MEDIC, OIG, Google Alerts, etc.) impacting pharmacy business
- Researches and monitors assigned region for potential Pharmacy FWA
- Prepares reports and presentations based on identified schemes
- Collaborates with clients
- Reviews and assesses quality and accuracy of client deliverables
- Collaborates with Manager, Supervisor, Analysts and Sr. Auditors to support overall FWA prevention and detection efforts and ensure case quality
- Leads special projects as assigned
- Create and maintain policy and procedures/job aids
- Provides ideas and recommendations on process improvements
- Must have ability to travel 4-6 weeks per year for 4-5 nights at a time
- High School Diploma/GED (or higher)
- Current and unrestricted Pharmacy Technician License in your state of residence (with ability to obtain Indiana Pharmacy Technician license within 3 months of hire)
- Currently certified by the PTCB (Pharmacy Technician Certification Board)
- 3+ years of recent experience working as a Pharmacy Technician: retail, clinic, hospital or PBM
- 1+ years of experience in project management, managing multiple contractual deliverables & timelines and/or administrative experience
- 1+ years of experience with the creation of reports for client, utilizing and analyzing data from multiple sources
- Intermediate level of proficiency in Excel (ability to analyze data w/in or across multiple workbooks)
- Must have ability to travel 4-6 weeks per year for 4-5 nights at a time
- Bachelor's degree
- PBM experience
- PBM audit/investigation experience
- SQL, DOMO, Access and/or SharePoint experience
- Intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance specifically Medicaid programs
- Proficient in RxClaim
- Excellent communication skills, written and verbal
- Solid organizational skills
- Detail oriented
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Pharmacy Audit Analyst - Fort Wayne, United States - UnitedHealth Group
Description
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
Working Schedule: 8 hour shift anytime between Monday - Friday 7am - 5pm EST. Please note you must reside in the state of Indiana, Kentucky, or Illinois.
If you reside in Indiana, Kentucky, or Illinois, you'll enjoy the flexibility to telecommute* as you take on some tough challenges.
Primary Responsibilities:
The challenge for you will be the high volume of cases on your plate at one time. You will be part of a team responsible for triaging, investigating and resolving instances of healthcare fraud and / or abusive conduct.
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
Preferred Qualifications:
Competencies:
*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
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 .
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 .
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