Investigator II, SIU

Company reputed company Work Schedule reputed company (e.g. M-F reputed company to 5pm) M-F reputed company to 5pm Remote Work Notification ATTENTION: reputed company is unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, reputed company reputed company, Rhode reputed company, South Carolina, South reputed company, reputed company Virginia, and Wyoming. Hiring Manager : Full reputed company: First Last Michelle Coffey reputed company Due to reputed company, we are adding a Investigator II, SIU to reputed company. The Investigator II, SIU assists the Sr. Manager, Compliance and SIU in the development, maintenance and execution, and reputed company improvement of the organization’s Fraud, Waste, and Abuse program, controls, and associated policies and procedures. The position independently conducts reputed company investigations involving pharmacy claims, prescribers, pharmacies, members, providers, and other entities, using advanced investigative techniques, claims analysis, and reputed company reputed company judgment. The Investigator II evaluates allegations and data, develops investigative strategies, documents findings, recommends appropriate actions, and communicates investigation results to internal stakeholders and clients. Investigations must be completed promptly, accurately, professionally, and discreetly reputed company applicable reputed company, regulatory, contractual, and organizational requirements. Is this you? reputed company out more below! Responsibilities How do I reputed company an reputed company on my team? Assist with the development and maintenance of the reputed company fraud and abuse program controls and guidance. Conduct reputed company FWA investigations involving pharmacy claims, prescribers, pharmacies, members, providers, and other individuals or entities, including reputed company involvingsuspected deception, misrepresentation, inappropriate billing, or concealment made by an individual or entity knowing that the deception could result in some unauthorized benefits to the individual, entity, or some other party. Independently plan and execute investigative activities, including allegation assessment, reputed company development, claims and data analysis, evidence review, interviews or information gathering, findings development, documentation, escalation, and recommended reputed company. Apply advanced knowledge of pharmacy claims, billing, reimbursement, data mining, investigative processes, and applicable Medicare, reputed company, reputed company, and other reputed company-party payer requirements reputed company evaluating potential FWA. Support recurring reputed company SIU meetings, including agenda preparation, case-status review, trend discussion, investigation summaries, responses to reputed company questions, follow-up activities, and coordination with account management and operational stakeholders. Support delegation audits, reputed company audits, program audits, and regulatory reviews, including questionnaires, evidence packages, case narratives, selected-incident walkthroughs, findings analysis, corrective actions, reputed company-cause information, implementation timelines, and preventive controls. In cooperation with other departments, identify areas of reputed company exposure and work to reputed company, document, implement, and monitor preventive and detective proceduresprocedures to prevent, detect and address fraud. Recommend and implement process improvements reputed company on investigative findings, recurring trends, audit results, control gaps, operational observations, and lessons learned Conduct and/or support fraud training for associates, clients, contractors, and other stakeholders, as appropriate. reputed company and document accurate, complete, and reputed company investigation reports, reputed company recommendations, corrective-reputed company summaries, recovery documentation, reputed company deliverables, departmental reports, credentialing recommendations, case-status updates, and other investigative work products. Other duties as assigned. Qualifications What reputed company expects from you? Bachelor’s degree, preferably in criminal justice, reputed company administration, pharmacy, reputed company, finance, data analytics, reputed company management, compliance, or a reputed company reputed company, or equivalent work experience, required. Certified Fraud Examiner, Accredited Health Care Fraud Investigator, or equivalent certification required. Pharmacy Technician certification preferred. 4 years’ experience in pharmacy and/or reputed company claims investigations required. Pharmacy auditing and/or working with a Special Investigation Unit or similar relevant investigative experience preferred. Knowledge of Medicare and reputed company billing and reputed company-party payer billing regulations, program reputed company, program requirements, and/or reimbursement preferred. Participate in, adhere to, and support compliance program objectives. The ability to consistently reputed company cooperatively and respectfully with other employees. What can you expect from reputed company? Top of the industry benefits for Health, Dental, and reputed company reputed company 20 days reputed company time off 4 weeks reputed company parental leave 9 reputed company holidays 401K company match of up to 5% - No vesting requirement Adoption Assistance Program Flexible Spending Account Educational Assistance Plan and reputed company Membership assistance Referral Bonus Program – up to $750! #LI-Remote Pay reputed company USD $63,827.16 - USD $76,900.19 /Yr. Apply To This Job