Director, Pharmacy Audit - Telecommute

Optum is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)  

The Director, Onsite Pharmacy Audit will be responsible for overall strategy, oversight, and supervision of the pharmacy network audit onsite audit team.They will be responsible for developing and enhancing processes to improve quality of service to our clients and set team direction.They need to be flexible and adapt to department plans and priorities and provide input to forecasting and planning activities.This role also oversees additional functional groups that perform onsite evaluations of company pharmacies for compliance with pharmacy practice requirements, as well as evaluation of adherence to OSHA guidelines related to occupational health and safety.This role performs routine assessment of employees for adherence to defined metrics and supports regulatory guidance to senior leadership. The Pharmacy Network Audit team’s primary responsibility is to audit and monitor for Fraud, Waste, Abuse and Error (FWAE) in our network of contracted pharmacies, and to ensure the accuracy of claims submitted by network pharmacies. This individual will ensure compliance with all state and federal pharmacy audit regulations and that key controls are in place to maintain compliance in the audit department. This leader will also be involved in resolution of escalations resulting from audits. 

You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. 

Primary Responsibilities:

• Lead teams across multiple functions related to onsite reviews and audits for pharmacy compliance and FWAE activity, including staff across the US as well as international resources
• Create strategic design for the FWAE onsite audit program of network pharmacies, ensuring it meets or exceeds industry standards and levels of service
• Oversee team performing pharmacy practice compliance audits of company pharmacies
• Provide oversight and direction to team responsible for onsite reviews to assess occupational safety at company pharmacies
• Ensure operations of the team are aligned to contract limitations and requirements
• Achieve annual recovery and revenue targets
• Develop and implement onsite audit selection criteria using machine learning and AI technology
• Communicate feedback and statistics on analytic model performance with technology partners
• Administer projects that will support ongoing innovation with strategic audit rules / logic and enhancements to improve operation efficiency using technology capabilities
• Develop and implement onsite audit workflow case management system
• Work to align onsite audit workflow with other operational areas and facilitate cross-training of staff
• Partner with Investigative audit team for referral of suspect activity
• Collaborate with key stakeholders under Commercial, Medicaid and Medicare lines of business to support audit needs for OptumRx’s clients
• Provide direct consultation to the appeal oversight and review committees
• Direct oversight and responsibility for preparing, updating, reviewing and approving pharmacy audit policies and procedures, including relevant job aids
• Preparation of departmental analytics and executive level presentations

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Bachelor’s degree or higher (or 11 years of practical experience in lieu of education)
• 7 years of experience in Pharmacy, preferably PBM
• 5 years of experience with pharmacy audit, including onsite
• 5 years of experience managing a team
• Experience with pharmacy claims processing systems and case management software
• Proficient with Microsoft Office: Word, Excel, PowerPoint, and Outlook
• Must be willing and able to travel up to 25% 
• Full COVID-19 vaccination is an essential requirement of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance

Preferred Qualifications:  

• PTCB certification
• State licensed pharmacy technician
• Experience with data analysis and manipulation of data
• Experience managing a remote team
• Retail pharmacy experience/industry exposure 
• Exposure to fraud, waste and abuse program development or oversight
• Microsoft Access knowledge
• Highly organized with excellent communication skills
• Excellent people skills with ability to drive team engagement
• Solid analytical skills

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with OptumRx. We're one of the largest and most innovative pharmacy benefits managers in the US, serving more than 12 million people nationwide. Here you’ll fill far more than prescriptions. As a member of one of our pharmacy teams, you’re empowered to be your best and do whatever it takes to help each customer. You'll find unrivaled support and training as well as a wealth of growth and development opportunities driven by your performance and limited only by your imagination. Join us. There's no better place to help people live healthier lives while doing your life's best work.(sm)

Colorado, Connecticut or Nevada Residents Only: The salary range for Colorado residents is $113,500 to $218,100. The salary range for Connecticut / Nevada residents is $113,500 to $218,100. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected bylower 48 law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.