Associate SIU Investigator
Posted on Dec 9, 2018 by Prime Therapeutics LLC
Job Posting Title
Associate SIU InvestigatorJob Description
The Associate 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 to ensure proper identification of potential FWA. The Associate SIU Investigator prepares investigative reports for leadership, internal committees and/or referral to state and federal law enforcement agencies.
+ Stays current on industry trend and best practices to understand potential fraud indicators and risk mitigation; make recommendations to SIU and Credentialing regarding enhancements or required changes to process
+ Uses sound investigative techniques in compliance with federal, state and local laws pertaining to investigations; independently applies judgment and evaluates risk of pharmacy potentially joining the network throughout the investigative process
+ Develops investigative plans, documents and justification to support investigations; proactively communicate plans, progress and changes to department leadership, Credentialing and other internal or external stakeholders
+ May evaluate pharmacies applying to join the network for potential fraud; investigate pharmacy purchase history and public records and make recommendations on next steps; ensures investigative actions align to department policy and practice
+ Adhere to evidentiary requirements, quality metrics, and other performance indicators required per SIU procedures
+ May recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; may recommend onsite visits 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
+ 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
+ 2 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
+ 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
+ Certified Fraud Examiner or Accredited Health Care Fraud Investigator
+ Licensed Pharmacist or National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
+ Solid skill and understanding of point of sale and on-line pharmacy claims processing environment
Minimum Physical Job Requirements
+ 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
+ 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. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at 1. or email .