Job Details

Siu Investigator - Remote

At Prime Therapeutics (Prime), we are reimagining pharmacy solutions to provide the care we would want for our loved ones. That purpose energizes our team and creates limitless opportunities to make a difference. We know that people make all the difference. If you're ready for a purpose-driven career and are passionate about simplifying health care, let's build the future of pharmacy together.

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 to 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 include developing investigative plans, documents, and justification to support investigations; evaluating impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicating 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. Other duties as assigned.

Minimum qualifications include a 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. Must have 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 include change agility 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 judgment 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 include 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 JUD; 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.