Senior SIU Pharmacy Investigator Resume Example Unitedhealthcare, SIU Compliance

SENIOR SIU PHARMACY INVESTIGATOR

Summary

To obtain a position within a progressive organization that will enable me to put to practice skills developed through past work experience as well as room for advance placement.

Experience

UnitedHealthcare, SIU ComplianceDecember 2018 to CurrentSenior Pharmacy Investigator, SIU
Chicago, IL

Investigate medium to highly complex cases of pharmacy Fraud, Waste and Abuse (FWA).
Conduct data mining and analysis for potential flags.
Detect fraudulent activity by members, providers, employees and other parties against the Company.
Manage large caseloads and allegations provided internal and externally.
Develop and deploy the most effective and efficient investigative strategy for each investigation.
Maintain accurate, current and thorough case information in the Special Investigations Unit's (SIU's) case tracking system.
Collect and secure documentation or evidence and prepare summaries of the findings.
Collect, collate, analyze and interpret data relating to fraud, waste and abuse referrals.
Ensure compliance of applicable federal/state regulations or contractual obligations.
Report suspected fraud, waste and abuse to appropriate to federal or state government regulators.
Comply with goals, policies, procedures and strategic plans as delegated by SIU leadership.
Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at work-groups or regulatory meetings.
Execute unannounced pharmacy inspections to ensure compliance. with state and / or federal regulations, codes and statutes.
Attend at least 30 hours of continuing education anti-fraud training annually.
Attend monthly meetings with: OIG, FBI and DEA.

Optum RxOctober 2016 to December 2018Pharmacy Investigator
Houston, TX

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.
Validate purchase invoices and / or other applicable documentation, as well as correlating billing records.
Verify current on - hand inventory, as well as acquire a complete listing of wholesalers.
Execute unannounced pharmacy inspections to ensure compliance with state and / or federal regulations, codes and statutes.
Verify the validity of all addresses associated with pharmacies including, but not limited to, Google Map's searches.
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.

UnitedHealthcareMay 2012 to October 2016Prior Authorization Pharmacy Technician
Sugarland, TX

Enter prior authorization request and verify appropriate information.
Resolve claim issues by contacting insurance companies.
Consult with pharmacy technicians and/or physicians regarding use of medications.
Perform all duties and functions in compliance with state and federal pharmacy laws and regulations.
Perform telephonic customer outreach to improve health quality outcomes.
Provide additional telephonic engagement with pharmacies.
Answer prior authorization inquiry calls or/and faxes as well as research and resolve formulary and benefit issues using the appropriate reference material.
Resolve issues and complaints in a timely manner.
Managed inventories, rotated stock, removed expired or damaged drug products and resolved discrepancies in drug counts.
Checked medications for content, accuracy and completeness of all drug packaging and labeling to provide final verification of prescription.
Received written prescriptions and refill requests from patients, evaluating information for completeness and accuracy before filling.

WalgreensDecember 2003 to August 2011Senior Certified Pharmacy Technician
Chicago, IL

In accordance with state and federal regulations, assists the pharmacist, under direct supervision, in the practice of pharmacy. Assists the pharmacist in the performance of other Pharmacy Department duties in accordance with Company policies and procedures.
Responsible for using pharmacy systems to obtain patient and drug information and process prescriptions.
Reports, immediately, prescription errors to pharmacist on duty and adheres to Company policies and procedures in relation to pharmacy errors and the Quality Improvement Program.
Assists and supports Pharmacy Department on inventory management activities, such as, ordering, unpacking, checking and storing shipment of pharmaceuticals. Maintains knowledge of Company asset protection techniques, and files claims for warehouse overages (merchandise received, but not billed), shortages (merchandise billed, but not received), order errors or damaged goods involving Rx drugs.
Assists with exterior and interior maintenance by ensuring the Pharmacy Department is stocked with adequate supplies, clean, neat and orderly in condition and appearance.

Education and Training

Sam Houston State UniversityAugust 2019Bachelor of Science: in Criminal Justice Huntsville, TX

Notre Dame HS For GirlsJune 2003High School DiplomaChicago, IL

Certifications

Pharmacy Technician Certification Board (PTCB)- Certification number 410101070962367, initial certification date 10/12/2007.

Resume Overview

Companies Worked For:

UnitedHealthcare, SIU Compliance
Optum Rx
UnitedHealthcare
Walgreens

School Attended

Sam Houston State University
Notre Dame HS For Girls

Job Titles Held:

Senior Pharmacy Investigator, SIU
Pharmacy Investigator
Prior Authorization Pharmacy Technician
Senior Certified Pharmacy Technician

Degrees

Bachelor of Science : in Criminal Justice
High School Diploma

Senior SIU Pharmacy Investigator Resume Example

Resume Score: 80%

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