Prescription Solutions is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
If you're ready to talk about groundbreaking interactions, let's talk about what happens when a firm that touches millions of lives decides to gather results from millions of prescriptions every month and analyze their impact. Let's talk about smart, motivated pharmacy teams. Let's talk about more effective and affordable health care solutions. This is caring. This is great chemistry. This is the way to make a difference.
***Shift for this position is Monday-Friday, 7:30a.m. to 4:30p.m.***
Responsibilities:
- Positions in this function analyze and monitor claims against fraud, waste and abuse related to retail pharmacy and long-term care networks.
- Investigates, reviews and analyzes claims data applying knowledge of pharmacy policy and practice and data mining techniques to determine details of fraudulent, erroneous, or abusive billing activity.
- May conduct on-site audits at pharmacies, physician offices and long-term care facilities.
- Site audits include assessment of physical premises, compliance with regulatory requirements, and completeness of provider/clinical records and itemized bills.
- Identifies and documents fraudulent or erroneous activities determined as a result of an audit.
- Prepares audit reports and determines overpayments.
- Formal documentation may be prepared for chief compliance officer and company attorneys.
- Notifies and works with government enforcement agencies as appropriate.
- Carries out complex investigation research activities involving FWA for members, prescribers, and pharmacies.
- Coordinates with Management to gain appropriate levels of documentation to support audit FWA position for network provider terminations.
- Assist supervisor in coordination of desk-top and on-site audit prep, workpaper documentation standards are met, and findings summaries timely created.
- Accountable for departmental production goals as with the other auditor.
- First level of escalation for issues, and questions from staff.
- Moderate work experience within own function.- Some work is completed without established procedures.
- Basic tasks are completed without review by others.
- Supervision/guidance is required for higher level tasks.
Prescription Solutions is an empowering place for people with the flexibility to help create change. Innovation is part of the job description. New ideas are welcome. And passion for improving the lives of our customers is a motivating factor in everything that happens.
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