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Senior Investigator - Irvine, CA

UnitedHealth Group

Irvine, CA
Job Code:
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Job Details

Senior Investigator - Irvine, CA(Job Number:727206)

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 Senior 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 broker community. This individual will be utilizing information from claims data analysis, plan members, employee's conduct confidential investigations and document relevant findings. They will report any illegal activities in accordance with all laws and regulations. The Senior 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 with identifying, communicating and recovering losses as deemed appropriate. Where applicable. they will provide testimonials regarding the investigation.


Primary Responsibilities:

  • Manages database tools for internal processing of various components of pharmacy audit reports received from contracted vendor
  • Maintain daily interface with audit vendor and coordination of network audit functions between ORx and audit vendor
  • Coordinate the development of pharmacy audit result reports as needed
  • Contributes to team effort by consistently meeting established productivity, schedule adherence, and quality standards while maintaining a good attendance record
  • Perform comprehensive Quality Assurance
  • Work collaboratively with others
  • Evaluate metrics and recommend process improvements
  • Demonstrates a clear understanding of goals, objectives, policies, procedures and priorities
  • Oversee / present pharmacy referrals to the Network Provider Evaluation Committee (NPEC) and pharmacy fraud investigation team
  • Initial point of contact for pharmacies in relation to appeals and audit escalation
  • Develops various standard and ad hoc reports
  • Analyzes and investigates
  • Provides explanations and interpretations within area of expertise

Job Special Investigation Unit
Primary Location US-CA-Irvine
Other Location 
Organization OptumRx Audit & Regulatory
Schedule Full-time
Number of Openings 1
Apply on the Company Site

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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