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 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; obtaining and reviewing factual and reliable evidence to support investigative outcomes; evaluating reports of potential fraud in Siu and making recommendations on next steps; ensuring investigative action aligns with department policy and practice; providing recommendations to audit operations and/or Siu regarding enhancements or required changes to process; adhering to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluating risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per Siu procedures; recommending referrals to client Sius, regulatory agencies, and/or law enforcement; recommending retention of experts or private investigators, surveillance or other expenditures to support investigations; and 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; and 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 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; and knowledge and understanding of pharmacy and medical claims processing environment.