Job Details

Special Investigations Unit (SIU) Investigator - Remote

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. The Special Investigations Unit (SIU) Investigator is responsible for conducting standard 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 investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies.

Responsibilities:

• Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholders
• Obtain and review factual and reliable evidence to support investigative outcomes; evidence reviews may include invoice documentation, entity interviews, background checks, pharmacy documentation, licensing information, proof of delivery and payment level information
• Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process
• Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures
• Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations

Minimum Qualifications:

• Bachelor's degree 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
• 2 years of work experience in investigation, audit, healthcare or legal Must be eligible to work in the United States without the need for work visa or residency sponsorship

Additional Qualifications:

• Change agile with a willingness and ability to adjust direction based upon changing priorities and business need while working with a high degree of autonomy
• Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions
• Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders
• Ability to distill complex concepts or situations into concise and compelling communications
• Knowledge and understanding of pharmacy and medical claims processing environment

Preferred Qualifications:

• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI)
• National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
• Licensed Practical Nurse (LPN) or Registered Nurse (RN)
• Experience working with RxClaims and/or JUDI
• Previous audit and investigation experience
• Pharmacy background within retail, mail order, hospital, or compounding setting
• Data mining experience
• Excel experience

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures. Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills.

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays.