Principal Investigator Pharmacy - Dallas and Houston, TX

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

Travel: Up to 50% in the Dallas and Houston, TX areas. Applicants must be within commutable distance to Dallas and Houston, TX.

If you reside in Dallas, Houston, TX or surrounding area, 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 Dallas and Houston, TX or surrounding areas, with the ability to travel up to 50% in the Dallas and Houston, TX area
• 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)<