SIU Investigator – Fraud, Waste & Abuse (FWA)

Prime Therapeutics
April 14, 2019
Eagan, MN
Job Type


Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make.

Job Posting Title
SIU Investigator - Fraud, Waste & Abuse (FWA)

Job Description
As a Special Investigations Unit (SIU) Investigator, you would be responsible for conducting standard and/or complex investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA). You would actively conduct claims data mining, fraud analysis, and auditing/monitoring activities and proactively identify improvement opportunities in audit and investigation procedures and FWA prevention efforts to ensure proper identification of potential FWA. As an SIU Investigator, you would also prepare investigative reports for remediation actions, recovery efforts, and/or referral to state and federal law enforcement agencies.


  • Evaluates reports of potential fraud in the Special Investigations Unit (SIU) and makes recommendations on next steps; ensures investigative action align to department policy and practice
  • Stays current on industry trend and best practices to understand potential fraud indicators and risk mitigation; make recommendations to audit operations and SIU regarding enhancements or required changes to the process
  • Uses sound investigative techniques in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; independently applies judgment and evaluates risk to determine how best to proceed with investigations based on the allegations
  • Develops investigative plans, documents and justification to support complex investigations, investigations of emerging fraud schemes and other investigations as needed; evaluate changing circumstances or newly discovered evidence that may warrant changes to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholders
  • Adhere to evidentiary requirements, quality metrics, and other performance indicators required per SIU procedures
  • Recommends referrals to client SIUs, regulatory agencies, and/or law enforcement; recommends retention of experts or private investigators, surveillance or other expenditures to support investigations
  • Establish effective working relationships between Prime and industry or client partners, law enforcement, and other key stakeholders
  • Uses appropriate judgment in providing risk advice to internal and external partners; ensures any issues are reported to department leadership as necessary
  • Represent Prime in a positive and professional manner during all pharmacy interactions and effectively de-escalate potentially confrontational situations
  • Other duties as assigned

Minimum Qualifications

  • Bachelor of Science/Arts in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required
  • 5 years of investigative or audit experience, preferably in a special investigations role
  • Must be eligible to work in the United States without a need for work visa or residency sponsorship

Additional Qualifications

  • Ability to work with a high degree of autonomy while ensuring appropriate communication and collaboration with department leadership and other team members
  • Change agile; willing and able to adjust individual and team direction based upon changing priorities and business need
  • Ability to think critically, problem solve and make decisions while anticipating the broad impact of decisions
  • Ability to establish trust, respect and credibility and form close working relationships with individuals at all levels of an organization; collaborates effectively cross-functionally and with clients and other external partners
  • Demonstrated ability to distill complex concepts or situations into concise and compelling communications
  • Expert communication, negotiation and influencing skills
  • Proven ability to maintain discretion and confidentiality

Preferred Qualifications

  • Certified Fraud Examiner or Accredited Health Care Fraud Investigator
  • Licensed Pharmacist or National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
  • Nurse
  • Solid skill and understanding of the point of sale and online pharmacy claims processing environment

Minimum Physical Job Requirements

  • Ability to travel up to 10% of the time
  • Constantly required to sit, use hands to handle or feel, talk and hear
  • Frequently required to reach with hands and arms
  • Occasionally required to stand, walk and stoop, kneel, and crouch
  • Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
  • Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus

Reporting Structure

  • Reports to SIU Manager in the Pharmacy Audit and FWA department

Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage qualified minority, female, veteran, disabled, and other diverse candidates to apply and be considered for open positions

Company Description

Everything we do is connected to helping people get the medicine they need to feel better and live well. It’s meaningful work and we’ve been doing it for over 20 years.

In the pharmacy benefit management (PBM)industry, we’re different. We’re owned by 18 not-for-profit Blue Cross and Blue Shield health plans. This allows us to control costs and empower our employees to put members first. It’s a successful combination. We have the lowest pharmacy trend in the industry and serve 27+ million members throughout the US.

In addition to core PBM services, we work closely with our clients to implement the right benefit design, clinical and specialty programs, formulary and networks. A few key products:
• NetResults™
• Specialty Drug Management
• Best in Care™
• GuidedHealth®
• Advanced Fraud, Waste and Abuse: Member and Prescriber Investigations
• Prime Analytics™
• CareCentered Contracting™Controlled Substance Management Program

Join us!
Prime is always looking for smart, purposeful people to join our team. We’re growing fast which means there are plenty of opportunities to advance and grow in your career.

At the same time, Prime supports flexibility and offers generous PTO so you can enjoy an enviable work/life balance. We’re a privately held company -big enough to make a difference and small enough for you to have an impact.