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Special Investigations Unit
4 months ago
**Position Responsibilities**:
- Develop and manage an effective fraud, waste, or abuse (FWA) program in accordance with applicable laws, regulations, accreditation requirements, and other guidance.
- Develop and implement internal SIU/FWA policies and procedures, including processes for routine FWA audits and other prevention, detection, and correction activities.
- Utilize various investigative techniques and tools to gather evidence and proactively identify potential FWA activity, including identifying trends and patterns of FWA activity through data mining and analytics.
- Investigate incidents related to pharmacy, member, and/or prescriber potential FWA.
- Analyze complex information and draw conclusions that support investigative findings.
- Prepare detailed reports and presentations on investigation efforts, findings, and remediation recommendations.
- Monitor and track outcomes of investigations to ensure appropriate actions are taken and potential risks are mitigated.
- Maintain strict confidentiality and adhere to ethical standards in all aspects of investigations.
- Develop FWA training and education for workforce members, Board members, and enrollees to enhance knowledge and skills related to FWA detection, reporting, and investigation.
- Collaborate with departments to implement a cross-functional FWA workgroup focused on FWA prevention and detection strategies and initiatives.
- Prioritize and manage workload effectively to ensure timely and accurate completion of investigations and other tasks.
- Stay up to date on industry regulations and best practices related to fraud detection and prevention.
- Develop and maintain collaborative relationships with internal departments, clients’ FWA/SIU professionals, law enforcement, and regulatory agencies.
- Testify in court or other legal proceedings as needed.
- Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.
**Required Qualifications**:
- National Health Care Anti-Fraud Association certification (AHFI), Certified Fraud Examiner (CFE), or America’s Health Insurance Plans Health Care Anti-Fraud Associate (HCAFA) designation.
- Bachelor’s degree in healthcare, Criminal Justice, Law Enforcement, or another related field. Extensive work experience may be considered in lieu of degree(s).
- 5+ years of experience in fraud investigation, a special investigation unit, Medicare or Medicaid fraud detection unit, or a related field, including two (2) years of active experience in auditing and investigating in the healthcare industry.
- Knowledge of federal and state laws related to healthcare FWA. This includes a solid understanding of applicable statutes such as the False Claims Act, anti-kickback statute, and Stark law.
- Strong analytical and critical thinking skills.
- Excellent communication and interpersonal skills.
- Attention to detail & commitment to delivering high-quality work products.
- Ability to balance multiple complex projects simultaneously.
This position reports to Capital Rx’s Chief Compliance Officer.
Base Salary: $100,000 - $150,000
**_Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. _**
**About Capital Rx**
Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp, Capital Rx is executing its mission through the deployment of JUDI®, the company’s cloud-native enterprise health platform, and a Single-Ledger Model, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.
**_Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws._
