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Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)

The Pharmacy Audit Rep Sr. will work on a wide range of activities to support pharmacy operations and initiatives to help meet goals and deliverables. Conducts audits of pharmacy claims in alignment with prior authorization requests and conducts audits of various pharmacy initiatives. Responsible for gathering and evaluating data from multiple sources to support ongoing pharmacy daily operations. Assist pharmacy leadership with business process and policy development of programs and productivity metrics. Assist with report development and analysis to support key initiatives and operations. 

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

Primary Responsibilities:

• Supports daily operations for high volume of pharmacy pre-service requests for high cost Part B drugs
• Assist in analyzing and monitoring pharmacy claims against fraud, waste, abuse and errors related to claims processed for Part B drugs
• Assist in conducting audits of pharmacy initiatives to ensure daily work aligns with established policies and job aids
• Conduct audits of systems to ensure alignment of system configurations and prior authorization requirements
• Coordinate, track, and report out results of user acceptance testing across multiple systems
• Assists in the development of tools to track operational metrics and monitor current initiatives
• May answer inbound calls from internal and external customers and assists them with their inquiries and routes calls to appropriate department if necessary
• Coordinates with all team members to keep workflow/initiatives on track
• Performs audit of staff documentations to ensure accuracy of the information documented as well as standard processes are followed
• Performs desk and on-site review of claims documentation to validate pharmacy processes and correct payment made to contracted providers
• Assists leadership and other related department team members in the implementation of programs or projects, including planning, developing, implementing and evaluating programs and projects, coordinating project activities, collaborating with project team members, and monitoring progress toward achievement and other projects as assigned
• Prepares draft agendas for meetings for review with leadership and assists with scheduling necessary meetings with team and other stakeholders
• Records minutes and takes detailed notes during meetings and provides follow-up correspondence
• Prepares reports, presentations, verbal/written correspondences, policies, communications, procedures and other required documentation as instructed by leadership
• Performs moderately complex business operation analysis and conducts research, analyzes/interprets information on issues, proposals and problems to ensure that adequate data is provided to leadership for decision-making and informational purposes
• Analyzes processes and presents findings to functional leads to develop or improve processes, services and/or programs to support the goals of the enterprise
• Manages multiple tasks at one time with successful outcomes
• Able to serve as a liaison between business and IT to document business and /or technical requirements
• Performs all other related duties as assigned

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:

• High School Diploma or GED
• 1+ years of experience in process improvement initiatives
• Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements
• Working knowledge of Medicare Part B and Part D coverage guidelines and payment methodologies
• Working knowledge of SharePoint
• Proficiency with Microsoft Office applications to include Word, Excel, Visio, PowerPoint and Outlook

Preferred Qualifications:

• Associate’s Degree in business, customer service or healthcare related field 
• 2+ years of experience with tracking, planning projects, and making data-driven analytical decisions
• Project Management experience
• Auditing experience
• Experience with process mapping methodology and creating process maps
• Health plan, healthcare or clinic operations experience
• Ability to independently solve moderately complex problems
• Ability to work in a fast paced environment on multiple projects with tight deadlines while paying close attention to the details of all the deliverables
• Ability to plan, prioritize, organize and complete complex work efforts to meet established objectives
• Ability to successfully develop action plans and execute the plan through implementation

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 WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.

Colorado, Connecticut, Nevada, or New York City Residents Only: The hourly range for Colorado residents is $18.17 to $32.26. The hourly range for Connecticut/Nevada/New York City residents is $20.00 to $35.53. 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 employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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 by law.

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