Senior Investigator - Pharmacy Fraud

At UnitedHealthcare, we are on a mission to simplify the health care experience, foster healthier communities, and eliminate barriers to quality care. Your work here will positively impact millions of lives. Join us in building a responsive, affordable, and equitable health care system of tomorrow. Are you ready to make a difference? Come, let’s start Caring. Connecting. Growing together. The Senior Investigator - Pharmacy Fraud plays a crucial role in identifying, investigating, and preventing fraud, waste, and abuse in healthcare. This position involves analyzing claims data and leveraging applicable guidelines to detect questionable billing practices. You will conduct thorough investigations that may include fieldwork, interviews, and collecting essential records. Travel: Up to 50%. Applicants must reside within commuting distance to Los Angeles County. If you live in Los Angeles, CA, you will have the flexibility to telecommute while tackling challenging issues. Key Responsibilities: Assess and investigate complaints regarding alleged misconduct within the Company. Examine medium to highly complex cases related to healthcare fraud, waste, and abuse. Identify fraudulent activities involving members, providers, employees, and other parties. Develop and implement effective investigative strategies tailored to each case. Maintain comprehensive and accurate case information in the Special Investigations Unit's (SIU) tracking system. Gather and secure documentation or evidence, preparing detailed summaries of findings. Engage in settlement negotiations and create investigative materials as needed. Communicate effectively, both in writing and verbally. Set goals and objectives, monitor progress, and adapt to evolving priorities. Collect and analyze data relating to fraud, waste, and abuse referrals. Ensure adherence to federal/state regulations and contractual obligations. Report suspected fraud, waste, and abuse to the appropriate regulatory authorities. Follow the established goals, policies, procedures, and strategic plans set by SIU leadership. Collaborate with state and federal partners, attending workgroups or regulatory meetings as directed. Why Consider UnitedHealth Group? Join us for a competitive salary and an extensive benefits package including: Paid Time Off starting from your first paycheck, plus 8 Paid Holidays. Multiple Medical Plan options and participation in a Health Spending Account or Health Saving Account. Comprehensive Dental, Vision, Life & AD&D Insurance, along with Short-term and Long-term Disability coverage. 401(k) Savings Plan and Employee Stock Purchase Plan. Education Reimbursement and Employee Discounts. Employee Assistance Program and Referral Bonus Program. Voluntary Benefits such as pet insurance, legal insurance, and LTC Insurance. You will be rewarded for your performance in a supportive environment that offers clear guidance for success in your role and provides opportunities for advancement. Required Qualifications: Bachelor's Degree OR an Associate's Degree with 2+ years of relevant healthcare experience. 2+ years of experience in healthcare, specifically dealing with fraud, waste, and abuse. 2+ years of understanding state or federal regulatory FWA requirements. 2+ years of data analysis experience related to identifying FWA trends. Intermediate proficiency in Microsoft Excel and Word. Intermediate knowledge of pharmacy claims processing. Capability to participate in legal proceedings, arbitration, and depositions as needed. Residency within the greater Los Angeles County area with the ability to travel up to 50%. Access to reliable transportation and a valid driver's license. Preferred Qualifications: 2+ years of experience with healthcare policies, procedures, and documentation standards. 2+ years of experience in developing investigative strategies. Specialized training in healthcare FWA investigations. Active affiliations with organizations such as: National Health Care Anti-Fraud Association (NHCAA) Accredited Health Care Fraud Investigator (AHFI) Certified Fraud Examiner (CFE) Licensed and/or Certified Pharmacy Technician (CPhT) Operational experience within a pharmacy or pharmacy benefits manager (PBM). All telecommuters must adhere to UnitedHealth Group's Telecommuter Policy. The salary range for this role is $60,200 to $107,400 annually, based on full-time employment. We adhere to all minimum wage laws applicable. At UnitedHealth Group, our mission is to support people in living healthier lives and improving the health system. We strive to address the barriers to health that many communities face, especially those historically marginalized. We are dedicated to delivering equitable care and improving health outcomes. UnitedHealth Group is an Equal Employment Opportunity employer, and all qualified applicants will be considered for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or veteran status, or any other characteristic protected by applicable laws. UnitedHealth Group is a drug-free workplace, and candidates will be required to pass a drug test prior to beginning employment.

Created: 2026-03-10