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We have modest goals: Improve the lives of others. Change the landscape of health care forever. Leave the world a better place than we found it. Such aspirations tend to attract a certain type of person. Crazy talented. Compassionate. Driven. To these individuals, we offer the global reach, resources and can-do culture of a Fortune 5 company. We provide an environment where you’re empowered to be your best. We encourage you to take risks and in return, offer a world of rewards and benefits for performance. Exceeding your limits is an exceptional start to your life's best work.SM


Just like you, we are driven by a set of fundamental principles that are guiding our way forward. Our values of integrity, compassion, relationships, innovation, and performance serve as a foundation to transform health care. Are you in? Learn more about your future at UnitedHealth Group at careers.unitedhealthgroup.com


Job Category:

Regulatory and Compliance



Postal Code:


Approximate Salary:

Not Specified

Position Type:

Full Time

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Pharmacy Credentialing Analyst - Boston, MA (Telecommute)

UHG - Boston, Massachusetts

Posted: 10/16/2018

Energize your career with one of Healthcare’s fastest growing companies.  


You dream of a great career with a great company – where you can make an impact and help people.  We dream of giving you the opportunity to do just this.  And with the incredible growth of our business, it’s a dream that definitely can come true. Already one of the world’s leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives.  We live for the opportunity to make a difference and right now, we are living it up.


This opportunity is with one of our most exciting business areas: Optum – a growing part of our family of companies that make UnitedHealth Group a Fortune 6 leader.


Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.

The Pharmacy Credentialing Analyst, working under the general direction and oversight of the Onsite Credentialing Manager, will conduct pharmacy analysis and onsite reviews of OptumRx Pharmacy Network. The Pharmacy Credentialing Analyst will conduct a full credentialing review of the pharmacy, including observing any potential or suspected civil or criminal fraudulent activity in connection with Medicare or Medicaid, or Commercial business of OptumRx Pharmacy Network.

Primary Responsibilities:
  • Analyst will work closely with Credentialing manager to validate that OptumRx Network pharmacies meet and maintain the appropriate credentialing requirements, as well as quality management standards to serve as a Pharmacy Provider for OptumRx
  • Analyst will perform background checks on all employees / entities, as well as further analytics to identify past / present associations with pharmacies terminated from the Pharmacy Network and / or engagement in FWA activity
  • Analyst will validate purchase invoices and / or other applicable documentation, as well as correlating billing records
  • Analyst will verify current on - hand inventory, as well as acquire a complete listing of wholesalers
  • Analyst will execute unannounced pharmacy inspections to ensure compliance with state and / or federal regulations, codes and statutes
  • Analyst will verify the validity of all addresses associated with Pharmacy including, but not limited to, Google Map’s searches and / or on - site visits
  • Obtain and analyze claims billing and payment data as necessary in the course of conducting an investigation of criminal or civil fraud
  • Prepare comprehensive case investigation reports including evidence and findings
  • Identify gaps and inefficiencies in existing policies and procedures and suggest effective and efficient solutions

Required Qualifications:

  • Bachelor's Degree (or higher) or High School Diploma / GED with 1+ years of experience working in Pharmacy Benefits Manager (PBM)
  • 3+ years of Pharmacy experience (Retail Pharmacy experience preferred)
  • National Pharmacy Technician Certification (CPhT)
  • Knowledge of Federal / State Requirements and Administrative Rules for Pharmacies
  • Ability to travel up to 50% of the time nationwide with overnight stays up to 5 days Monday - Friday
Preferred Qualifications:
  • 1+ years of prior investigative / auditing / credentialing experience
  • 2+ years of experience in data analysis
  • 1+ years of experience working with reporting tools and generating effective reports
  • Industry Certifications (CFE, AHFI, etc.)
  • Previous experience with Government Health Care Programs (Medicare, Medicaid and / or TRICARE)
  • Experience working within the Health Care Fraud Investigations or Compliance Organization related to Pharmacy setting and / or Law Enforcement Agency
  • Knowledge of top industry dispensed medications, Federal Requirements, and Specific State Requirements to perform the Credentialing Review
Soft Skills:
  • Excellent attention to detail and concise documentation
  • Excellent time management and organizational skills
  • Able to work independently in a fast-paced environment
  • Ability to convey complex information to others and make it more easily understood

OptumRx is an empowering place for people with the flexibility to help create change. Innovation is part of the job description. And passion for improving the lives of our customers is a motivating factor in everything we do.


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 teams. Let's talk about more effective and affordable healthcare solutions. This is caring. This is great chemistry. This is the way to make a difference. We're doing all this, and more, through a greater dedication to our shared values of integrity, compassion, relationships, innovation and performance.  Join us and start doing your life’s best work.

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.

Keyword: Pharmacy Benefits Manager ; investigation; auditing; Technician

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