SIU Investigator – Pharmacy Audit Fraud Waste & Abuse

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Published
July 29, 2019
Location
Saint Paul, MN
Job Type

Description

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 - Pharmacy Audit Fraud Waste & AbuseJob Description

The Special Investigations Unit (SIU) Investigator is responsible for conducting standard and/or complex investigations of potential pharmacy, member, and/or prescriber fraud, waste and abuse (FWA).

This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in audit and investigation procedures and FWA prevention efforts to ensure proper identification of potential FWA. The investigator prepares investigative reports for remediation actions, recovery efforts, and/or referral to state and federal law enforcement agencies.

Responsibilities

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 the 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 investigative or audit experience, preferably in a special investigations role

Must be eligible to work in the United States without 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 point of sale and on-line 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.

Prime Therapeutics' fast-paced and dynamic work environment is ideal for proactively addressing the constant changes in today's health care industry. Our employees are involved, empowered, and rewarded for their achievements. We value new ideas and work collaboratively to provide the highest quality of care and service to our members.

If you are looking to advance your career within a growing, team-oriented, award-winning company, apply to Prime Therapeutics today and start making a difference in people's lives.

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.

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