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Associate Director Operations Pharmacy Audit

Irvine, CA

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The Associate Director Operations, Pharmacy Audit will be responsible for overall strategy, oversight and supervision of the pharmacy audit operations team. The Pharmacy Audit teams primary accountability and responsibility is to audit and monitor for any Fraud, Waste, and Abuse in our network of contracted pharmacies, and to ensure the accuracy of the claims submitted by the pharmacies. This individual will assess critical details, pharmacy documentation, audit outcomes, recording and reporting for senior management and is accountable for teams achieving targeted audit goals. They 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 escalated inquiries/cases and correspondences that are related to audits / investigations.
Primary Responsibilities:
Provide direct consultation to the appeal oversight and review committees
Oversee compliance and monitoring of corrective action plans issued through pharmacy audits
Direct oversight and responsibility for preparing / updating, reviewing and approving pharmacy audit policies and procedures, including relevant job aids
Work directly with the management teams of the retail pharmacies that are within our network
Work with regulatory affairs and professional practice and policy areas in monitoring new legislation and proposed changes to existing legislation relating to pharmacy audit policy
Act as liaison with appropriate regulatory and state boards
Support research of regulatory authority governing audits and findings
Oversee CMS and other regulatory or data validation audits
Coordinate annual training for pharmacy audit department staff ensuring all elements are clearly communicated, documented and reported accordingly
Drive innovation, operational improvements, and bench strength of pharmacy audit staff
Preparation of departmental analytics and executive level presentations
Presentations to existing and new clients on our Advanced Pharmacy Audit Services product as well as present at clients quarterly business reviews
Provide leadership to and accountable for the performance of Managers, Supervisors and staff
Function as Clinical SME for Audit leadership group
May provide clinical judgment and expertise in conjunction with audit activity
May assess technical / clinical internal and external correspondence
Administer projects that will support ongoing innovation with strategic audit rules / logic and enhancements to improve operation efficiency using technology capabilities
Required Qualifications:
Bachelors degree or higher
Experience driving innovation, operational improvement and reporting changes
Experience in mentoring and providing guidance to a team to encourage professional growth
3 years track record presenting data / info to executive and senior level management via outstanding communication / presentation and interpersonal skills
Proficiency with Microsoft Excel, Word, PowerPoint, Outlook
Preferred Qualifications:
Microsoft Access
3 years of direct management experience
Experience developing and working on budget forecasting
Licensed Pharmacist or professional pharmacy certification
Pharmacy industry background highly desired, and PBM experience
Exposure to fraud, waste and abuse program development or oversight
Experience in leadership role in special investigations unit in healthcare
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the worlds large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your lifes best work.(sm)
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 by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: Clinical SME for audit group, Irvine, CA, California
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