Special Investigations Unit (SIU) Investigator (Remote)

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
Special Investigations Unit (SIU) Investigator (Remote)
Job Description
The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential 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 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
- 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
- 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 of work experience in investigation, audit or legal to include 1 year of work experience in data or crime analysis
- Must be eligible to work in the United States without need for work visa or residency sponsorship
Additional Qualifications
- Change agile; willing and able to adjust individual and team 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
- Ability to interact positively and professionally during all member, prescriber and pharmacy interactions and effectively de-escalate potentially confrontational situations
Preferred Qualifications
- Certified Fraud Examiner or Accredited Health Care Fraud Investigator
- National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
- Licensed Practical Nurse (LPN) or Registered Nurse (RN)
- Prior experience in a special investigation unit
- Knowledge and understanding of pharmacy and medical 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
Reporting Structure
- Reports to a Manager in the Pharmacy Audit and FWA department
Potential pay for this position ranges from $55,400.00 - $83,400.00 based on location, experience and skills.
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (https://www.primetherapeutics.com/careers/benefits/) and click on the "Benefits at a glance" button for more detail.
Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.