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Senior Investigator - Multiple Locations

UnitedHealth Group

Iselin, NJ
Job Code:
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Job Details

Senior Investigator - Multiple Locations(Job Number:700020)

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, working under the general direction and oversight of the Special Investigations Unit (SIU) Manager, will conduct investigations of medium to 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 New Jersey, New York and Pennsylvania.


Primary Responsibilities:


Under the direction of the SIU Manager, the Senior Investigator 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



Job Special Investigation Unit
Primary Location US-NJ-Iselin
Other Location US-NY-New York, US-PA-Philadelphia
Organization UHC LCRA - Compliance
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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