What are the responsibilities and job description for the Special Investigations Unit (SIU) Investigator (Remote) position at Prime Therapeutics?
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
Education & Experience
Must be eligible to work in the United States without the need for work visa or residency sponsorship.
Additional Qualifications
Preferred Qualifications
Physical Demands
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
Potential pay for this position ranges from $59,000.00 - $94,000.00 based on experience and skills.
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail.
Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, creed, color, religion, gender, sexual orientation, gender identity / expression, national origin, disability, age, genetic information, veteran status, marital status, pregnancy or related condition (including breastfeeding), expecting or parents-to-be, or any other basis protected by law.
We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.
Prime Therapeutics LLC is a Tobacco-Free Workplace employer.
Positions will be posted for a minimum of five consecutive workdays.
Salary : $59,000 - $94,000
