The Senior Investigator, Pharmacy Fraud is responsible for carrying out complex investigations of alleged misconduct by Providers, Pharmacies, Representatives, Employees and Members.
Duties & Responsibilities:
- Conduct investigations of Providers, Pharmacies, Employees, Representatives and Members Investigations may be of a more complex nature i.e., multiple allegations; Medicaid, Medicare and commercial health benefit investigations or investigations involving extensive research, income verifications and other criteria for eligibility
- Assist SIU Management with Fraud, Waste and Abuse issues related to Pharmacy/Provider Fraud & Opioid abuse, and perform other duties as necessary or assigned
- Prepare, review and edit investigation reports for submission to SIU Management , Fraud, Waste & Abuse Committee and the Member Review Restriction Committee
- Collect, utilize and interpret data in order to identify patterns related to internal or downstream entity practices which merit further investigation
- Work collaboratively with Healthfirst’s Pharmacy Department and Clinical Teams including the SIU’s Nurse Coding Advisor
- Identify and highlight for SIU management potential misconduct or significant fraud schemes
- Exhibit a high level of organization and time management skills with an ability to balance and prioritize a diverse case load and determine appropriate next steps
- Demonstrate a high level of autonomy and organization in the course of investigations, including maintenance of electronic evidence files, checklists and case logs
- Demonstrate a high level of independence in screening allegations and development of initial case plan/theory of the case or using discretion to close allegations without viable leads
- Maintain good working relationship with internal and external business partners including Federal, State and Local law enforcement and regulatory agencies
- Interface regularly with off-site vendor who manages pre-pay and post-pay audits of providers and Healthfirst’s Pharmacy Benefit Manager
- Synthesize investigation into case recommendation for SIU Management HF executives and investigative Committees; such recommendations are given significant weight
- Assist with identification and execution of training activities, process improvement matters, or other risk mitigation efforts that benefit the entire team
- Mentor other Investigators and SIU Team members who need assistance for professional development and case management
- NY State requirements as follows: Bachelor’s Degree in criminal justice or related field , or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies
- Pharmacy formulary experience within a managed care or PBM environment
- Experience with Pharmacy/Prescriber Fraud Investigations
- Proficiency in MS Word, Excel, and Outlook
- Knowledgeable of applicable fraud statutes and regulations
- Ability to work independently with excellent time management skills while still contributing to the needs of the Team
- Strong critical thinking and analytical skills
- High degree of integrity as demonstrated by appropriate treatment of confidential information, adherence to policies, rules and regulations, professional conduct in dealing with persons internal and external to the organization, and sensitivity to target populations.
- Knowledge of medical claims processing and investigations
- Knowledge of Medicare and Medicaid products
- Intermediate excel skills including pivot tables
Compliance & Regulatory Responsibilities: N/A
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.
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